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PCA #01
The patient verbalizes and demonstrates understanding of proper use of PCA Pump (Patient Controlled Analgesia) for pain control.
Anesthesia
Nursing

Pacemaker Discharge #01
Your pacemaker is a device that can send an electrical signal to your heart when it is necessary. Please call your doctor if you feel dizzy, lightheaded, develop shortness of breath, are confused, more tired, or pass out (faint). Please follow up with your pacemaker doctor (Electrophysiologist) regularly to check your pacemaker. Your pacemaker battery usually will last 5 - 8 years. Please avoid certain electric or magnetic equipment. If you cannot walk through metal detector, ask for hand security search. Please consult your doctor before obtaining an MRI. Please follow directions that you received about arm use and mobility, driving, sex & sling use. Please consider obtaining an emergency medical bracelet telling people you have a pacemaker. Please tell any health care provider that you have a pacemaker.
Cardiology
Emergency Medicine

Syncope Discharge #01
HOME CARE INSTRUCTIONS: Have someone stay with you until you feel stable. Do not drive, operate machinery, or play sports until your caregiver says it is okay. Keep all follow-up appointments as directed by your caregiver. Lie down right away if you start feeling like you might faint. Breathe deeply and steadily. Wait until all the symptoms have passed.Drink enough fluids to keep your urine clear or pale yellow. If you are taking blood pressure or heart medicine, get up slowly, taking several minutes to sit and then stand. This can reduce dizziness. SEEK IMMEDIATE MEDICAL CARE IF: You have a severe headache. You have unusual pain in the chest, abdomen, or back. You are bleeding from the mouth or rectum, or you have a black or tarry stool. You have an irregular or very fast heartbeat. You have pain with breathing. You have repeated fainting or seizure-like jerking during an episode. You faint when sitting or lying down. You have confusion. You have difficulty walking. You have severe weakness. You have vision problems. If you fainted, call your local emergency services - do not drive yourself to the hospital.
Cardiology
Emergency Medicine

Hyperlipidemia Goals #01
In order to maintain a LDL<70 please eat a heart-healthy diet that is low in saturated fats and salt and includes whole grains, fruits, vegetables and lean protein; exercise regularly (consult with your physician or cardiologist first); maintain a heart healthy weight; if you smoke - quit and please continue to take your prescription medications as directed.
Cardiology
Endocrinology

Aortic Stenosis Discharge #01
Aortic stenosis is a condition when the aortic valve in the heart does not open fully so less blood flows out of the heart. Subsequently, the heart has to work harder than usual to pump the blood out of the heart to the rest of the body. You may have a heart murmur as a consequence. Please call your doctor with shortness of breath, dizziness or fainting, or chest pain, which will increase with physical activity. Your doctor will do echocardiograms to monitor the condition. Take your cardiac medications as directed to minimize cardiac workload - it is important to keep your blood pressure & cholesterol levels under control. Speak to your doctor about physical activity since this will depend on the severity of your condition.
Cardiology
Medicine

Cardiac Catheterization #01
The patient was objectively evaluated clinically and found to be at significant risk for coronary artery disease. The patient will undergo a left heart catheterization and possible percutaneous coronary intervention.
Cardiology
Medicine

Congestive Heart Failure (CHF) Discharge #02
Please take medications as prescribed. Follow up with your doctor as directed. Eat a heart healthy diet low in salt, sugar & fat. Limit sodium intake to 1500 - 2000 mg per day. Restrict your fluid intake to 1.5 - 2 quarts per day. Remember to weigh yourself every morning after voiding, record & report weight gain to your doctor as discussed. Call your doctor for swollen legs, ankles & feet, shortness of breath when you lie down or if you are coughing up pink and foamy or bloody sputum. Call 911 for chest pain, shortness of breath or for signs & symptoms of stroke.
Cardiology
Medicine

Congestive Heart Failure (CHF) Discharge #03
You should return to the hospital if you begin to have persistent chest pain especially if it radiates to the arm/jaw/back, shortness of breath or chest pain with exertion that is different than normal for you, worsening in any lower extremity edema (swelling), sudden onset of cold sweats with difficulty breathing, or for any other concerns. For more information on Congestive Heart Failure please visit the American Heart Association's Website at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp
Cardiology
Medicine

Congestive Heart Failure DC #01
HOME CARE INSTRUCTIONS: Weigh yourself daily. If you gain 3lbs in 3 days, or 5lbs in a week call your doctor. Do not eat or drink foods containing more than 2000mg of salt (sodium) in your diet every day. Call your physician if you have any increasing in swelling in your feet, ankles, and/or stomach. Take all of your medication as directed. If you become dizzy or chest pain please call your primary care doctor.
Cardiology
Medicine

Postcath #01
No heavy lifting, bending, straining, or unnecessary activity for 2 weeks. No driving for 2 days post procedure. You may shower 24 hours following the procedure but avoid bath-tubs, hot-tubs and/or swimming for 1 week. Check your groin site for bleeding and/or swelling daily following procedure; call your doctor immediately if it occurs or if you experience increased pain at the site.
Cardiology
Surgery

Postcath #02
No heavy lifting, driving, sex, tub baths, hot-tubs, swimming, or any activity that submerges the lower half of the body in water for 48 hours. Limited walking and stairs for 48 hours. Change the Band-Aid after 24 hours and every 24 hours after that. Keep the puncture site dry and covered with a Band-Aid until a scab forms. Observe the site frequently. If bleeding or a large lump (the size of a golf ball or bigger) occurs lie flat, apply continuous direct pressure just above the puncture site for at least 10 minutes, and notify your physician immediately. If the bleeding cannot be controlled, call 911 immediately for assistance. Notify your physician of pain, swelling or any drainage. Notify your physician immediately if coldness, numbness, discoloration or pain in your foot occurs.
Cardiology
Surgery

Angioplasty DC #01
Angioplasty or coronary stenting are procedures that open up narrowed/blocked coronary arteries in the heart. A stent is a tiny metal tube that helps open an artery in the heart muscle. Your doctor will instruct you when you can drive or resume usual physical activities You MUST take aspirin & another agent (e.g. Plavix) to help prevent clots inside the stent. It is VERY important to take these medications as directed UNLESS your cardiologist says it is OK to stop. The most common problems after coronary stenting are: bleeding, bruising, & soreness at the groin insertion site - you can use Tylenol for discomfort if not contraindicated. Call your doctor if you have chest pain, fever, pain, swelling, or redness where the groin insertion occurred
Cardiology

Cardiac Catheterization Consent #01
Cardiac catheterization w/ coronary angiogram and possible stent placement-consent obtained. The patient is competent, has the capacity, and understands risks and benefits of procedure (including possible alternatives). The risks which include, but are not limited to: bleeding, infection, CVA, PE, MI, arrhythmias, cardiac tamponade, CHF, retroperitoneal bleeding, pseudoaneurysm, other various vascular complications, kidney failure, allergic/contrast reactions, dissections or other various thromboembolic complications were explained to the patient in layman's terms. The patient clearly understands risks and decides to proceed with the procedure as planned.
Cardiology

Chest Pain #01
The patient's risk factors for ACS were reviewed as well as the EKG. The CXR assists in r/o Pneumonia, Pneumothorax, Esophageal Tears. The patient does not appear to have a Pulmonary Embolism based on the Wells Score and PERC rule and there is no apparent DVT. There are no signs of Pericarditis, Endocarditis, or Myocarditis based on risk factor analysis. There is no fever. There does not appear to be an Aortic Dissection either based on history, physical exam, and signs.
Cardiology

Chest Pain DC #01
HOME CARE INSTRUCTIONS: For the next few days, avoid physical activities that bring on chest pain. Continue physical activities as directed. Do not smoke and avoid drinking alcohol. Only take over-the-counter or prescription medicine for pain, discomfort, or fever as directed by your physician. Follow your physician's suggestions for further testing if your chest pain does not go away. Keep any follow-up appointments you made. If there is any problem keeping an appointment, please call to reschedule. SEEK MEDICAL CARE IF: You think you are having problems from the medicine you are taking. Read your medicine instructions carefully. You develop chest pain does not go away, even after treatment. SEEK IMMEDIATE MEDICAL CARE IF: You have increased chest pain or pain that spreads to your arm, neck, jaw, back, or abdomen. You develop shortness of breath, an increasing cough, or you start coughing up blood. You have severe back or abdominal pain, feel nauseous, or vomit You develop severe weakness, fainting, or chills. You have a fever. THESE ARE EMERGENCIES - Do not drive yourself to the hospital.
Cardiology

Coronary Artery Disease DC #01
Coronary artery disease is a condition where the arteries that supply the heart muscle get clogged with fatty deposits. This puts you at risk for heart damage and/or heart attack. PREVENTION: Lifestyle changes including, but not limited to, quitting smoking, if you smoke, eating lots of fruits, vegetables & low-fat dairy products, limiting your intake of meat and fatty foods. Please walk or participate in some form of physical activity at least 5 days a week and lose weight if you are overweight. Take your medications as prescribed. Make sure to keep appointments with your doctor for follow-up care. SEEK MEDICAL CARE: If you develop any chest pain, pressure, or discomfort; pain, tingling or discomfort in arms, back, neck, jaw, or stomach; shortness of breath, nausea, vomiting, burping or heartburn, sweating, cold and clammy skin, racing or abnormal heartbeat for more than 10 minutes or if they keep coming & going.
Cardiology

Hypertension Goals #01
Please eat a low salt, low cholesterol diet. Please exercise regularly and maintain a healthy body weight. Please take your blood pressure medication as prescribed.
Cardiology

Arterial Line Placement #01
An arterial line was placed under {ultrasound guidance/not under ultrasound guidance.} A-line flushes and has blood return. Positive SQ wave test and has good a waveform. Extremity has good coloration and cap refill < 2 seconds, sensation intact. Will continue to monitor.
Critical Care
Nursing

Cellulitis Discharge #01
Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
Dermatology
Infectious Disease

Intubation #01
The indication for the procedure is XXX. Respiratory therapy and nursing staff were present. The patient was monitored with continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen by non-rebreather mask and nasal cannula prior to intubation. The patient was sedated with *** IV MEDICATION*** and paralyzed with XXX mg of *** IV PARALYTIC*** . Once adequate sedation and paralysis were obtained a ***DIRECT LARYNGOSCOPY METHOD*** was used to directly visualize the vocal cords and an XXX endotracheal tube was placed through the cords, inflated and secured at XXX cm. Endotracheal tube placement was confirmed with capnography and bilateral breast sounds in the lungs. Post procedure chest X-ray showed the ETT to be in good position above the carina. I was present for the entire procedure and there were no complications.
Emergency Medicine
Anesthesia

Intubation #03
*** consent was obtained. Patient was preoxygenated, placed in appropriate position, paralyzed and sedated using ***. Using direct laryngoscopy, patient intubated using a MAC *** and a **** diameter ETT, placed to a depth of **** at the lips. There were no complications, patient tolerated procedure well, bilateral breath sounds were auscultated. Placement confirmed with positive end tidal CO2 color change and chest xray showing appropriate ETT placement.
Emergency Medicine
Anesthesia

Cardioversion #01
Consent (verbal and/or written) was obtained after the risks and benefits were discussed. The indication for the procedure was XXX. The patient had been NPO for greater than 4 hours. Respiratory therapy and nursing staff were present and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. The total time for the procedure was *** minutes and I was present for the entire procedure and there were/were not complications.
Emergency Medicine
Cardiology

Chest Pain Negative Statement
No evidence of ACS, pericarditis, myocarditis, pulmonary embolism, pneumothorax, pneumonia, Zoster, or esophageal perforation. Historically not abrupt in onset, tearing or ripping, pulses symmetric, no evidence of aortic dissection.
Emergency Medicine
Cardiology

Hypertension Admit #01
During the patients emergency department stay they were noted to have at least one blood pressure measure reading greater than 120/80. Due to this measurement I discussed with the admitting doctor the need to monitor the patients blood pressure and, if necessary, start the patient on medications to control the patients blood pressure.
Emergency Medicine
Cardiology

Hypertension Discharge #01
During the patients emergency department stay they were noted to have at least one blood pressure measure reading greater than 120/80. Due to this measurement I verbally educated the patient on hypertension and recommended they follow-up with their primary care doctor in the next 5-7 days for repeat measurement of their blood pressure and if it remains persistently elevated that their primary care doctor may start them on medications to control their blood pressure. I also recommended several lifestyle modifications (weight loss, dietary sodium restriction, increase physical activity and moderate alcohol consumption).
Emergency Medicine
Cardiology

Orthostatic Hypotension Discharge #01
Your blood pressure can drop when you change positions too fast especially from lying to standing. Please get up slowly first by put your feet on the floor and then wait five minutes while letting your feet dangle to prevent drop in blood pressure upon standing. Medications can cause worsened symptoms. Be sure to drink adequate fluids to keep hydrated , continue medications as ordered , report worsening symptoms to your primary care provider, use assistive devices to transfer and ambulate
Emergency Medicine
Cardiology

STEMI #01
The patient was immediately placed in a monitored bed, and IV was placed, oxygen was administered, and the EKG was evaluated. The ECG revealed an acute ST elevation myocardial infarction. A code STEMI was called XXX time and the cath lab was activated. I spoke with DR. XXX of cardiology who agreed to take this patient directly to cardiac catheterization. Defibrillator pads were placed on the patient. The patient was given Aspirin and Plavix. After a chest x-ray was performed which showed no mediastinal widening IV heparin was given based on the patients weight. The patient had normal hemodynamics during the ED course and was taken directly to the cardiac cath lab.
Emergency Medicine
Cardiology

Syncope Negative Statement
No evidence of a cardiac arrhythmia such as Brugada, WPW, HOCM, Long or short QT. Neurologic exam is nonfocal, not consistent with CVA or primary neurologic abnormality.
Emergency Medicine
Cardiology

Arterial Line Placement #02
After consent was obtained, the right/left radial/brachial/axillary/femoral region was prepped and draped in the standard sterile fashion. Collateral flow was confirmed to the extremity by occlusion of the artery. The artery was then punctured with pulsatile flow confirmed and a guidewire passed into the vessel. The needle was removed and a catheter was easily inserted into the artery over the guidewire. The guidewire was then completely removed and the catheter attached to the pressure transducer in a sterile fashion. Once an adequate wavefore was confirmed, the catheter was secured in place. The patient tolerated the procedure well without complications
Emergency Medicine
Critical Care

Cardiac Arrest JG #01
During the code, possible causes of asystole were reviewed, including hypoxia (100% oxygen via XXX tube), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on phys exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology.
Emergency Medicine
Critical Care

Central Line Procedure Note #01
The risks were noted to include bleeding and pneumothorax. The indication for the procedure were XXX. A timeout was performed. Nursing staff were present and the patient was monitored using telemetry and continuous pulse oximetry. The patient was placed in the Trendelenburg position and the neck was prepped chlorhexidine and a sterile full body drape was placed. Sterile technique including gown, mask, and gloves were used and antibacterial hand gel was used before gloving. The ultrasound machine, using a sterile probe cover, was used to visualize the internal jugular vein by the compression technique. The skin was anesthetized with local infiltration with 3 cc of 1% lidocaine and an 18 gauge finder needle was used to enter the internal jugular vein. Venous blood was aspirated and a guidewire was threaded through the needle into the vein. The soft tissues were dilated and the needle was removed. An XXX was threaded over the guidewire in the standard Seldinger technique and secured at XXX cm. The guidewire was removed and all ports flushed and aspirated blood without difficulty. A sterile dressing and Biopatch were applied. A postoperative chest X-ray showed the line to be in good position in the XXX without any evidence of pneumothorax. I was present for the entire procedure and there were no complications.
Emergency Medicine
Critical Care

Central Line Procedure Note #02
Informed consent was obtained after explaining benefits, risks, and alternatives to care. The area prepped/draped in sterile fashion. The vessel was visualized under ultrasound guidance. Finder needle inserted under direct visualization with US and venous non-pulsatile blood return obtained. Guidewire inserted, finder needle removed, introducer catheter inserted and removed. Catheter inserted via Seldinger technique. Guidewire removed. Blood return from each port and flushed. Secured with sutures and covered with Tegaderm. Insertion confirmed with chest xray.
Emergency Medicine
Critical Care

Conscious Sedation #02
INDICATION: XXXX. Informed consent obtained. The patient is AAOx3 before procedural sedation. No prior problems with anesthesia or sedation. Procedural sedation performed using XXXX mg of XXXX. Adequate anesthesia and analgesia achieved. Patient on a cardiac monitor and nasal cannula during the procedure, and had no signs of respiratory distress. Pt monitored until AAOx3 again. Pt tolerated sedation with no complications.
Emergency Medicine
Critical Care

Critical Care JG #01
Given the critical condition in which the patient arrived, the patient was immediately assessed by myself and the nurse, and cardiac monitoring initiated due to the potential for rapid decompensation of the patient's clinical condition. During the course of the patients stay, I spent a considerable amount of time at the bedside performing serial re-evaluations of the patient's hemodynamic and clinical status because of the recognized potential threat to life or limb in this condition. I then had a chance to review not only all of the available current laboratory and radiographic studies obtained today, but I also reviewed old records available to me at the time. Additionally, any ancillary information available including paramedic records were reviewed. Sequential vital signs were obtained. Critical Care time of XXX minutes was performed exclusive of billable procedures
Emergency Medicine
Critical Care

Expiration Discharge #01
Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupil were fixed and dilated at 8mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at __________. Patient's family was contacted and did not desire autopsy, chaplain services were offered, and funeral arrangements were discussed.
Emergency Medicine
Critical Care

Intubation #02
Airway assessed andthe patient was adequately preoxygenated with NRB. The patient was placed in the optimal sniffing position for intubation. RSI used to pre-medicate patient. Intubated with XXX ETT to XXX cm measured at the lip, cuff inflated, stylet removed. Placement confirmed by CO2 color capnography, bilateral breath sounds, equal chest rise, and chest xray confirmation.
Emergency Medicine
Critical Care

Paracentesis #02
PROCEDURE: Diagnostic & Therapeutic Paracentesis, U/S guided. The area of the LEFT/RIGHt abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. 1% lidocaine was used to numb the region. The paracentesis catheter was inserted and advanced with negative pressure under ultrasound guidance. No blood was aspirated. Clear yellow fluid was retrieved and collected. Ascitic fluid WAS/WAS NOT collected and sent for laboratory analysis. The catheter was then connected to the vaccutainer and XXX liters of additional ascitic fluid were drained. The catheter was removed and no leaking was noted. The patient tolerated the procedure well without any complications.
Emergency Medicine
Critical Care

Ultrasound IV Placement #01
A peripheral IV catheter was placed under dynamic ultrasound guidance with dark nonpulsatile blood return. Catheter confirmed in compressible vein post insertion via ultrasound. No extravasation in surrounding site after the procedure. Will continue to monitor.
Emergency Medicine
Critical Care

Negative Rash Statement
No evidence of erythema multiforme, SJS/TEN, Lyme, cellulitis, necrotizing fasciitis, no angioedema, meningococcemia, rocky mountain spotted fever.
Emergency Medicine
Dermatology

Rash Discharge #01
Does not appear at this time to be erythema multiforme, bullous, SJS, TEN; no evidence at this time to suggest RMSF or endocarditis or Lyme disease; patient looks well, nontoxic and is tolerating oral intake; no neurologic signs or symptoms; no headache or photophobia or neck pain; no ev of sepsis; question viral exanthema; afebrile; appropriate for initial o/p tx; d/w pt importance of f/u and pt agrees/understands; told pt to return to nearest ER immediately for any worsening ssx incl but not limited to: fever, spreading rash, pain, sore throat, headache, dizziness, chest pain, trouble breathing, or any ssx concerning to the patient. I did d/w pt the aforementioned ddx as possibilities and pt understands to f/u even if better and to return to ER if un-changed/worse. Pt understands these instructions on d/c and is comfortable with discharge plan.
Emergency Medicine
Dermatology

Constipation Discharge #01
Take Colace 100-200 mg up to three times per day. You may take along with Senokot 1-2 tabs, ingest with full glass of water. Maintain fluid intake 6-8 glasses per day. Please increase fibers in your diet. You may also take Milk of Magnesia 30 mL as needed for constipation, you may repeat in 2 hours again if no bowl movement.
Emergency Medicine
Gastroenterology

Gastroentertitis Discharge #01
You should return to the hospital if you experience return of persistent nausea and vomiting that does not resolve and does not allow you to tolerate any food or fluids, persistent fevers for greater than 2-3 more days, increasing abdominal pain that persists despite medications, persistent diarrhea, dizziness, syncope (fainting), or for any other concerns. For more information about how to make your own rehydration solution if you experience diarrhea/vomiting please visit: http://rehydrate.org/solutions/homemade.htm
Emergency Medicine
Gastroenterology

Paracentesis #01
The indication for the paracentesis is XXXX. Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The ultrasound machine was used to identify the most accessible fluid pocket and the abdomen was prepped with betadine and draped in sterile fashion. Sterile technique including mask, gown, and gloves were used. The skin was anesthetized using 3 cc of 1% lidocaine and an 18 gauge introducer needle was used to aspirate peritoneal fluid and then a catheter was threaded through the needle. XXX cc of peritoneal fluid were taken from the abdomen and the catheter was removed. Peritoneal fluid ***WAS/WAS NOT*** sent for analysis. Gauze was placed where the procedure was performed. No persistent leak was appreciated. I was present for the entire procedure and there were no complications
Emergency Medicine
Gastroenterology

Against Medical Advice #01
The patient has requested to leave the ED against medical advice. The patient reason(s) for leaving include, but are not limited to, the following: XXXX. I believe this patient is of sound mind and competent to refuse medical care. The patient is responding and asking questions appropriately. The patient is oriented to person, place and time. The patient is not psychotic, delusional, suicidal, homicidal or hallucinating. The patient demonstrates a normal mental capacity to make decisions regarding their healthcare. The patient is clinically sober and does not appear to be under the influence of any illicit drugs at this time. The patient has been advised of the risks, in layman terms, of leaving AMA which include, but are not limited to death, coma, permanent disability, loss of current lifestyle, delay in diagnosis. Alternatives have been offered - the patient remains steadfast in their wish to leave. The patient has been advised that should they change their mind they are welcome to return to this hospital, or any other, at any time. The patient understands that in no way does an AMA discharge mean that I do not want them to have the best medical care available. To this end, I have provided appropriate prescriptions, referrals, and discharge instructions. The patient ***did/did not*** sign AMA paperwork. The above discussion was witnessed by another member of staff.
Emergency Medicine
General

Against Medical Advice Call Back #01
The patient had earlier left the Emergency Department against medical advice. I have called them back and discussed *** xxx *** with them OR left a message and encouraged and welcomed them to return to the Emergency Department to allow us to help them with their medical concerns.
Emergency Medicine
General

Against Medical Advice JG #04
The patient is clinically sober, AA&Ox3, free from distracting injury. Throughout our interactions in the ED today, the patient has demonstrated concrete thinking/reasoning, has maintained an orderly/reasonable conversation, appears to have intact insight/judgment/reason and therefore in our opinion has capacity to make decisions. Given the patients presentation, we communicated our concern for XXXX in laymans terms. The patient verbalized an understanding of our worries. Weve told the patient that the ED evaluation is incomplete & many troublesome conditions havent been r/o. We have discussed the need for further ED w/u so we can get more information about XXXXXX. We have discussed the range of possible dx, potential testing & treatment options. Weve made numerous efforts to prevent the pt from leaving AMA. Our discussions included the potential outcomes of leaving AMA, including worsening of their condition, becoming permanently disabled/in pain/critically ill, or death. Despite these efforts, we were unable to convince the pt to stay. The patient is refusing any further care and is leaving against medical advice. We have attempted to offer tx/rx/guidance for any dangerous conditions which are most likely and/or dangerous. We have answered all questions and have implored the patient to return ASAP to complete the w/u. A staff member witnessed the patient consenting to AMA.
Emergency Medicine
General

Fever Negative Statement
No evidence of encephalitis, bacterial meningitis, pneumonia, soft tissue infection, joint infection, meningococcemia, intraabdominal infection such as appendicitis, cholecystitis, no evidence of UTI, no risk factors or findings concerning for endocarditis, no evidence of lyme disease.
Emergency Medicine
Infectious Disease

Gonorrhea and Chlamydia Treatment #01
Will empirically treat for GC/Chlamydia with Ceftriaxone IM and Azithromycin. GC culture sent. Abstinence and safe sex precautions were provided and the patient demonstrated understanding.
Emergency Medicine
Infectious Disease

Sepsis Red Flags Negative #01
Patient denies cough, nasal congestion, abdominal pain, nausea, vomiting, recent antibiotic use, diarrhea, dysuria, urinary frequency, new rashes or injuries, headaches, neck stiffness, photophobia, and sick contacts.
Emergency Medicine
Infectious Disease

Motrin JG #01
Please take IBUPROFEN (aka MOTRIN, ADVIL) 400 mg and/or ACETAMINOPHEN (aka Tylenol) 500 mg every 6 hours, as needed, for pain. Please do not take these medications if you have a bleeding disorder, stomach or GI ulcer problems or liver disease.
Emergency Medicine
Medication

Opioid Discharge #01
Will discharge patient with a short course of opiates. Went over the risks of the medication. Advised patient to not mix with other products containing acetaminophen, to not combine with alcohol, or other illicit drugs, to not drive or operate machinery, and to refrain from any activity that will require complete attention while taking this medication.
Emergency Medicine
Medication

Percocet JG #01
Please take one tablet of PERCOCET every 6 hours, as needed for SEVERE pain. Please do not take this medication unless you absolutely need it, it is very addictive. Please do not drive, operate heavy machinery or make important decisions while on this medication, it can cloud your judgement.
Emergency Medicine
Medication

Against Medical Advice #02
I informed this patient of the need for further medical evaluation and care given the patient's current medical condition. This patient declined further medical evaluation and treatment. I informed this patient of the benefits of further medical evaluation and care at this facility. I informed this patient of the risks of leaving against our medical advice without properly completing our evaluation today that include illness, injury, permanent disability and even death. The patient was also informed about alternatives. I informed the patient of the possible necessity for hospital admission depending on future findings. At the time of discussion, this patient maintained full faculties of judgement and medical decision-making capacity. In accordance with this patient's wishes, the patient was discharged from the emergency department against our medical advice in stable condition with normal vital signs in no acute distress.
Emergency Medicine
Medicine

Against Medical Advice #03
At the time of discharge, this patient demonstrated full faculties medical capacity and judgement. In my conversation with this patient they demonstrated the following: 1. This patient demonstrated their ability to express and communicate their choice to leave the emergency department against medical advice and to refuse further medical care. 2. This patient demonstrated the ability to understand relevant information regarding their diagnosis including the purpose of recommended treatment for their stated medical condition. The patient remembered this information and demonstrated that they were part of the decision making process in the course of their care. 3. This patient appreciated the significance of their medical condition, their diagnosis, and the consequences for leaving the emergency department against medical advice and refusing further medical treatment. This patient demonstrated clear understanding of the benefits of further evaluation and treatment. This patient demonstrated clear understanding of the risks of leaving against medical advice and refusing further medical treatment that include injury, illness, permanent disability, and death. 4. This patient demonstrated the ability to manipulate information regarding their medical condition, their decision to leave the emergency department against medical advice, and their decision to refuse further medical care. The patient demonstrated appropriate reasoning and intact logical thought processes during our conversation and was able to weigh the risks and benefits of receiving further medical care.
Emergency Medicine
Medicine

Alcohol Discharge #01
Recommend cessation of alcohol use, or at the least avoid heavy alcohol consumption. Strongly recommend alcohol rehabilitation/ detox: see enclosed list of centers (you must make the calls yourself for entrance into the program). Return immediately if you develop signs of withdrawal.
Emergency Medicine
Medicine

Alcoholic #01
The patient drinks alcohol XXX times a week for XXX years. The patients last drink was XXX and amount XXX . Health education about alcohol drinking and hazards were given and we recommended to stop alcohol drinking.
Emergency Medicine
Medicine

Discharge JG #01
1) Please follow-up with your primary care doctor in the next 1-2 days. Please call tomorrow for an appointment. If you cannot follow-up with your primary care doctor please return to the ED for any urgent issues. 2) You were given a copy of the tests performed today. Please bring the results with you and review them with your primary care doctor. 3) If you have any worsening of symptoms or any other concerns please return to the ED immediately. 4) Please continue taking your home medications as directed.
Emergency Medicine
Medicine

History of Present Illness #01
Intensity / Severity, Quality / Character, Onset / Duration, Radiation, Context, Aggravating factors. Alleviating factors. Associated Signs and Symptoms
Emergency Medicine
Medicine

Review of Systems JG #01
Denies fever, chills, chest pain, SOB, palpitation, dizziness, weakness, N, V, D, abdominal pain, bladder and bowel problems, leg swelling, sick contacts, or recent travel.
Emergency Medicine
Medicine

Two Midnight Rule
At the time of this inpatient admission, I believe this patient will require at least two midnights of inpatient hospital care for the history, risk factors, comorbidities, findings, diagnoses and/or interventions listed:
Emergency Medicine
Medicine

Kidney Stone #01
Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with oral narcotics for pain control, Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
Emergency Medicine
Nephrology

Bells Palsy Discharge #01
Follow up with Neurology within 3-5 days. Please take Prednisone 60mg for 9 more days. Please take Valacyclovir 1000mg three times a day for 7 more days. Apply eye drops every 2 hours and tape your eye closed when you are asleep. Please return to the Emergency Department for any new or worsening symptoms.
Emergency Medicine
Neurology

Bells Palsy Discharge #02
You have a condition called Bells Palsy. You will be prescribed several medications to help alleviate this disease. 1)Please take the steroid PREDNISONE once a day for the next 7 day. 2)Please take the antiviral medication as directed. 3)Please use the artificial tears as directed. 4)Please tape the affected eye shut at night. This will prevent your eyes from drying out and potentinally developing a deep scratch called an ulcer.
Emergency Medicine
Neurology

Concussion Discharge #01
Based on the events which brought you to the ER today, it is possible that you may have a concussion. A concussion occurs when there is a blow to the head or body, with enough force to shake the brain and disrupt how the brain functions. You may experience symptoms such as headaches, sensitivity to light/noise, dizziness, cognitive slowing, difficulty concentrating / remembering, trouble sleeping and drowsiness. These symptoms may last anywhere from hours/days to potentially weeks/months. While these symptoms are very frustrating and perhaps debilitating, it is important that you remember that they will improve over time. Everyone has a different rate of recovery; it is difficult to predict when your symptoms will resolve. In order to allow for your brain to heal after the injury, we recommend that you see your primary physician or a physician knowledgeable in concussion management. We will give you a list of neurologists, they are the specialists for head injuries. We also advise you to let your body and brain rest: avoid physical activities (sports, gym, and exercise) and reduce cognitive demands (reading, texting, TV watching, computer use, video games, etc). School attendance, after-school activities and work may need to be modified to avoid increasing symptoms. We recommend against driving until until all symptoms have resolved. You should take 650mg of Acetaminophen (Tylenol) every 4 hours as needed for pain control; however, taking anti-inflammatory medication (Motrin/Advil/Ibuprofen) is not advised. Come back to the ER right away if you are having repeated episodes of vomiting, severe/worsening headache/dizziness or any other symptom that alarms you. We recommended that someone stay with you for the next 24 hours to monitor for these worrisome symptoms.
Emergency Medicine
Neurology

Dizzy or Syncope ROS #01
No evidence of an arrhythmia such as Brugada, WPW, HOCM, Long or short QT, significant AV dissociation, or significant bradycardia. Neurologic exam is nonfocal, not c/w CVA or primary neurologic abnormality.
Emergency Medicine
Neurology

Headache Medical Decision Making #01
The patient presents with an acute onset headache for {Hours/Days} in duration. Patient has no past history of headaches. There {Is/Is Not} a history of anticoagulation, trauma, pregnancy, cancer or immunocompromised state. Mental status was normal, no neurological deficits were noted. Differential Diagnosis considered includes hypertensive emergency, subarachnoid hemorrhage, meningitis, trauma, CVA, migraine. IV was placed and {Meds} given with {Outcome} relief of symptoms. CT head was negative for acute bleed, infarct, mass, or shift. LP was performed and was negative for WBC or xanthochromia/consistent with *** The patient improved significantly and was discharged in stable condition. Recommendations were given for follow-up with PCP in 1-2 days and to return to the ED for worsening of headache or any other concerns
Emergency Medicine
Neurology

Headache Medical Decision Making JG #01
Based on the patient's history and physical there is very low clinical suspicion for significant intracranial pathology. The headache was NOT sudden onset, NOT maximal at onset, there are NO neurologic findings, the patient does NOT have a fever, the patient does NOT have any jaw claudication, the patient does NOT endorse a clotting disorder, patient DENIES any trauma or eye pain and the headache is NOT associated with dizziness or ataxia. Will treatment the patient symptomatically and reassess.
Emergency Medicine
Neurology

Head Trauma Discharge #01
Follow up with your primary care doctor within 48-72 hours. Rest. Take Acetaminophen (Tylenol) every 4-6 hours, as needed, for pain. Often individuals develop a headache associated with nausea in the days/hours after a head injury. This is called a concussion and does not warrant a return to the ED UNLESS: you develop significant worsening of pain, profuse vomiting, dizziness, changes in vision, difficulty walking/speaking, weakness or numbness to your extremities.
Emergency Medicine
Neurology

Lumbar Puncture #03
Both verbal and written consent were obtained, patient informed of risks including pain, infection, bleeding and understands and accepts these risks. Patient placed in lateral decubitus position, draped and prepped in a sterile manner using betadine x 3, and locally anesthetized with 3 cc of 1% lidocaine. Approximating the L3/L4 interspace, a standard LP needle was placed in this location, yielding ***** fluid consistent with CSF. Patient tolerated the procedure well, there were no complications.
Emergency Medicine
Neurology

Negative Headache Statement
No evidence of subarachnoid hemorrhage, intracranial bleed, meningitis, encephalitis, temporal arteritis, or intracranial mass.
Emergency Medicine
Neurology

Neuro Red Flags #01
Patient denies new weakness on one side of the body, diplopia, vertigo, slurred speech, headache, or difficulty walking.
Emergency Medicine
Neurology

Seizure Discharge #01
Please follow up with Neurology in the next 1-2 days as an outpatient. Please continue taking your medications as prescribed. Do not drive or swim until cleared to do so by your neurologist. Return for worsening condition or any other emergencies.
Emergency Medicine
Neurology

Nurse ED Discharge #01
The patient was discharged from ED. IV lock removed. No erythema/infiltrate noted. The patient verbalized understanding of discharge instructions.
Emergency Medicine
Nursing

Diclegis #01
Please take 10 mg of Pyridoxine and 10mg of Doxylamine at bedtime. If that does not work increase to 20mg of each medicine on a daily basis at bedtime; if symptoms not adequately controlled, increase dose to 40mg tablets each day (10mg of each pill in AM, 10mg of each pill in the mid-afternoon, and 20mg of each pill at bedtime).
Emergency Medicine
Ob / Gyn

Pregnancy RhoGAM #01
Due to the patients abdominal pain and pregnancy status an ultrasound was performed to assess fetal location which showed XXX. Because the patient was having some vaginal bleeding as well their RH status was determined to be XXX and RhoGAM was / was not given.
Emergency Medicine
Ob / Gyn

Vaginal bleed Discharge #01
You should return to the hospital if you continue to have persistent and heavy vaginal bleeding, persistent pelvic pain not relieved by your prescribed medications, dizziness, shortness of breath, new and persistent fevers, other foul smelling discolored vaginal discharge, or for any other concerns. For more information about recommendations for heavy menstruation please visit the American College of Obstetrics and Gynecology Website at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women
Emergency Medicine
Ob / Gyn

Vaginal Bleed First Trimester #01
XX year old GXPX female presents with first trimester vaginal bleeding. Possible etiologies of the vaginal of bleeding were considered, including but not limited to: ectopic pregnancy, spontanous miscarriage, gestational trophoblastic disease, implantaton bleeding, molar pregnancy and fiborids. Clinically the patient looks well, no indications for transfusion and no signs or symptoms of peritonitis. An ultrasound was performed which showed XXX. Because the patient was having vaginal bleeding their RH status was determined to be XXX and RhoGAM {was / was} not given. Additional labs demonstrated: After careful consideration I believe the patient is safe to be discharged home with outpatient OB/GYN followup. I had an extensive disucssion with the patient about the possible etiologies of the vaginal bleeding and answered all their questions. I also provided education on prenatal care. The patient is agreeable to outpatient Ob/Gyn for a 48 hour BETA-HCG. I encouraged them to call if they have any questions and return to the ED for any worsening of symptoms.
Emergency Medicine
Ob / Gyn

Vaginal Bleed Medical Decision Making JG #01
Differential Diagnosis Considered: Adenomyosis, Cervicitis, Dysfunctional uterine bleeding, Ectopic pregnancy, Endometrial cancer, Hydatidiform mole, Implantation bleeding, IUD/contraceptives, Miscarriage, Placental abruption, Placenta previa, Polycystic ovarian syndrome, Postcoital bleeding, Postpartum hemorrhage, Retained products of conception, Uterine fibroids, Uterine polyp, Uterine rupture In evaluating this patient's complaint, multiple diagnoses were considered, including those listed above. Based on history, physical, clinical context, and any tests done today it is my judgment that the diagnosis/diagnoses considered do not apply to this patient and that the remaining diagnoses about either do not apply to this patient, or do not require additional emergent evaluation and treatment
Emergency Medicine
Ob / Gyn

Ankle Sprain #01
Rest, Ice and Elevation. Please take Motrin 600mg every 8 hours, as needed, for pain. Please follow up with Sports Medicine or your Primary Care Doctor in 48-72 hours for further evaluation - please call for an appointment. Please return to ED for increased pain, weakness, fever, redness, and/or tingling/numbness
Emergency Medicine
Orthopedic Surgery

Ankle Xray Read JG #01
No evidence of fracture or dislocation on prelim read of xray by ME
Emergency Medicine
Orthopedic Surgery

Arthrocentesis #01
Arthrocentesis of the LEFT/RIGHT JOINT was performed. The patients identity, procedure, and site were identified and confirmed to be correct. The appropriate equipment and staff were confirmed for the procedure. There was no evidence of overlying infection, osteochondral fracture, uncontrolled bleeding disorder, or joint prosthesis which would contraindicate arthrocentesis. The risks and benefits of this diagnostic procedure were discussed and verbal consent was obtained from the patient. The patient is AAOx3, has decisional making capacity. The skin over the joint was sterilized and then numbed with a local anesthetic. A needle was inserted into the joint w/ aspiration of XXX cc's of fluid. The fluid was sent to the lab for appropriate studies. Blood loss was minimal. A dressing was placed over the procedure site. The patient tolerated the procedure without any adverse events.
Emergency Medicine
Orthopedic Surgery

Back Pain Discharge #01
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Ambulate as tolerated and no heavy lifting. Take Motrin 600 mg every 8 hours for pain with food, Valium 5mg every 8 hours as needed for muscle spasm- do not drive or make any important decisions while on this medication for it can make you drowsy. If you experience any worsening pain, swelling, numbness, weakness please return to ER
Emergency Medicine
Orthopedic Surgery

Back Pain MDM #01
The patient presents with acute onset of back pain after XXX. Clinically this patient can be ruled out for serious pathology given there is a completely normal neurological exam, no history of IV drug use, and no history of bowel or bladder incontinence, no perianal numbness/tingling, no constipation or urinary retention. Once the patients pain was adequately controlled, the patient was able to ambulate and be discharged in stable condition with anticipatory guidance provided.
Emergency Medicine
Orthopedic Surgery

Back Pain Negative Statement
No risk factors or findings concerning for epidural abscess, diskitis, vertebral osteomyelitis, cord compression, cauda equina, vertebral fracture or bone malignancy, AAA, or pyelonephritis. Patient instructed to consider further imaging and workup through their primary care physician as an outpatient if symptoms persist.
Emergency Medicine
Orthopedic Surgery

Back Pain Red Flags #01
The patient endorse NO: fevers, chills, recent spinal procedures, bowel/bladder incontinence, IV drug use, cancer, > 50 yo, recent weight loss, trauma ,weakness numbness, tingling, dysuria, hematuria
Emergency Medicine
Orthopedic Surgery

Back Pain Red Flags #02
Patient denies fevers, IV drug use, recent back surgeries or procedures, urinary incontinence, and bowel incontinence.
Emergency Medicine
Orthopedic Surgery

Cast Care #01
Please keep your cast clean and dry, keep extremity elevated, and do not stick anything into the cast. Please use a garbage bag while showering to prevent water from entering the cast. If pain significantly worsens call or return to the Emergency Department.
Emergency Medicine
Orthopedic Surgery

Conscious Sedation #02
Indication: ***********. Pre-sedation history and examination revealed: ASA physical status 1E********; fasting duration ****** hours; family history ******(negative) for adverse anesthetic/sedative reactions; airway class ******; normal dentition/neck mobility; and no contraindications to sedation. Risks, benefits and alternatives were discussed with *************, who desired to proceed.  End tidal CO2, O2 saturation, and BP constantly monitored duringsedation. A qualified nurse and additional provider were present during the sedation. The patient received ***drug/route/dose**** , achieving an appropriate level of sedation. The patient then underwent ***reduction******. Total sedation time for which I was present was ****minutes***** until minimal consciousness and responsiveness achieved, and deep/moderate sedation was no longer present. There were no significant O2 desaturations or complications during this sedation and procedure. Patient was subsequently monitored until reevaluation revealed patient was back to neurologic baseline.
Emergency Medicine
Orthopedic Surgery

Finger Reduction #01
FINGER REDUCTION PROCEDURE NOTE: Finger reduction. Indication: dislocation of [left/right] [1st-5th] finger at the [DIP/MIP/PIP] joint. Consent: The risks and benefits of the procedure including incomplete reduction, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified Procedure: Anesthesia/pain control, using aseptic technique, was administered using a digital block of [ ] ml of 1% lidocaine. The patient's distal [left/right] [1st-5th] finger was grasped and longitudinal traction applied with slight exaggeration of the deformity. The joint was gently manipulated into its normal position. A finger splint was applied. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Fracture Discharge #01
Please rest, ice and elevate the affected extremity. Please take Motrin 600mg every 8 hours, as needed, for pain (take with food). Follow up with Orthopedic Surgery in 1-2 days for further evaluation - please call for any appointment. Keep splint/cast clean, dry and on. Please use garbage bag while showering to keep splint/cast dry. Use sling/crutches. Please return to ED immediately for increased pain, tingling/numbness, swelling, redness, and fever
Emergency Medicine
Orthopedic Surgery

Fracture Reduction #01
FRACTURE REDUCTION PROCEDURE NOTE: Fracture reduction Indication: Acute fracture with displacement, requiring fracture reduction. Consent: The risks and benefits of the procedure including incomplete reduction, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified Procedure: Neurovascular exam intact prior to fracture reduction. Skin exam : No bleeding or lacerations at the fracture site. Anesthesia/pain control, using aseptic technique, was administered using a hematoma block of [ ] ml of 1% lidocaine. Reduction of the [left/right] [fracture site] was accomplished via axial traction and careful manipulation. Following adequate reduction and alignment of the fractured bone, the fracture was immobilized with a plaster splint. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Hip fracture #01
The patient is status post mechanical fall c/o {Right/Left} hip pain and inability to walk. The patient denies head trauma or LOC. No other bone injuries noted by the patient. {RIGHT / LEFT} lower extremity is short and externally rotated. Skin: over {RIGHT / LEFT} hip is clean, dry and intact; Motor: EHL/FHL/GS/TA intact; Sensory: Grossly intact Pulse: 2+dp/pt
Emergency Medicine
Orthopedic Surgery

Joint Reduction #01
JOINT REDUCTION PROCEDURE NOTE: Joint reduction Indication: Dislocation of [left/right] [joint]. Consent: The risks and benefits of the procedure including incomplete reduction, secondary fracture, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified. Procedure: Neurovascular exam intact prior to joint reduction. Skin exam: no bleeding or lacerations at the fracture site. Conscious sedation performed by emergency department attending physician. Anesthesia/pain control, using aseptic technique, was administered using a hematoma block of [ ] ml of 1% lidocaine. Reduction of the [left/right] [joint] was accomplished via [ ]. The joint was immobilized with sling / splint. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Joint Reduction #01
Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. Nursing staff were present and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Once the patient was adequately sedated, the *** RIGHT/LEFT JOINT*** was reduced using the traction-counter traction technique. A postoperative X-ray revealed the joint to be adequately reduced. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. I was present for the entire procedure and there were no complications.
Emergency Medicine
Orthopedic Surgery

Orthopedic Injury Discharge #01
Rest, ice, elevate area. Apply ice to the area for 10 minutes every 2 hours for the first 2 days after the injury to reduce swelling. If you have any worsening of symptoms, including severe pain/swelling/redness/numbness/changes in sensation/weakness/paralysis or any other concerns please return to the Emergency Department immediately. Please follow up with your doctor(s) within the next 3 days, but seek medical care sooner if your symptoms persist or worsen. Please call as soon as possible for an appointment. If you cannot follow up with your doctor please return to the Emergency Department for any urgent issues. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist.
Emergency Medicine
Orthopedic Surgery

Splint #02
SPLINTING PROCEDURE NOTE: Splinting Indication: [fracture/dislocation/pain] The [area to splint] was appropriately positioned. A plaster splint was applied. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well.
Emergency Medicine
Orthopedic Surgery

Valium Discharge #01
Take Valium 5mg every 8hrs as needed for muscle spasm. This medicaiton can cause drowsiness. Do not drive or operate heavy machinery or make important decisions while on this medication.
Emergency Medicine
Orthopedic Surgery

Child Physical Exam #01
General: Well appearing, interactive with examiner, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, oropharynx clear, no lesions, TM clear bilateral; Neck: Supple, no meningismus, no CLAD; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended, no palpable mass; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Extremities symmetric, nontender.; Skin: No rash, normal skin tone, no eccymosis, purpura or petechiae.; Neuro: Alert and Oriented appriorate for age; No focal deficit, CN 2-12 symmetric and intact.
Emergency Medicine
Pediatrics

Child Protective Services
There is NO concern for any abuse/neglect or other child protective services-related issues at this time (parents appear to be appropriately engaged, concerned, and acting in the best interests of and for welfare of the patient), although the need for such concern has been thoughtfully considered.
Emergency Medicine
Pediatrics

Croup Discharge #01
Your pediatrician can reassess the need for additional Decadron (steroids) to help reduce inflammation and swelling. If your child's respiratory distress worsens or if your child has inspiratory stridor at rest which is not improved with repositioning, please call your pediatrician or return to Emergency Department.
Emergency Medicine
Pediatrics

Fever Negative Statement #02
No e/o encephalitis, bacterial meningitis, pneumonia, soft tissue infection, joint infection, meningococcemia, intraabdominal infection (appendicitis, biliary infection, intraabdominal abscess) , no risk factors or findings concerning for endocarditis, lyme disease, RMSF, or clinical symptoms/UA suggestive of UTI.
Emergency Medicine
Pediatrics

Infant Physical Exam #01
General: Well appearing, interactive with examiner, nontoxic, no acute distress; Head: Normocephalic Atraumatic, Fontanelle not sunken or bulging; Eyes: PERRL, EOMI; ENT: Airway patent; TM clear bilateral; Oral and nasal within normal limits, no lesions; Neck: No meningismus, supple; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended, no palpable mass; no guarding, rebound, or tenderness to percussion; Musculoskeletal: extremities symmetric, nontender; Skin: No rash, no eccymosis, petechiae, or purpura, Cap refill less than 2 seconds; normal skin tone; Neuro: Alert and Oriented appropriate for age; No focal deficit, CN 2-12 symmetric and intact, no pathologic reflexes; Genitourinary/Rectal: External genitalia unremarkable, no lesions
Emergency Medicine
Pediatrics

Laceration Repair #01
Area prepped and draped in sterile fashion. Anesthestized with lidocaine. Irrigated with copious irrigation and explored for foreign body. Sutured with XXX sutures with adequate approximation of wound edges. The wound was then covered with bacitracin and sterile guaze. Instructions given to return in XXX days for suture removal in the ED or with their primary care doctor.
Emergency Medicine
Pediatrics

Nursemaid Elbow Reduction #01
Firm supination of the forearm supporting the elbow in 90 of flexion. Felt and heard audible 'click' as full supination is achieved.
Emergency Medicine
Pediatrics

Pediatric ED return precautions #01
Please return to the emergency room for: persistent fevers, persistent vomiting, inability to tolerate liquids, decreased urination, change in mental status or any other concerns.
Emergency Medicine
Pediatrics

Pediatric Pneumonia Discharge #01
Routine Home Care as follows: Please continue to take your antibiotic as prescribe - ______, _____ mg every _____ hours, for a total of ____ more days. Make sure your child drinks plenty of fluid. Please continue to make sure your child is urinating every 6 hours. Please follow up with your Pediatrician in the next 1-2 days. If your child has any concerning symptoms such as: decreased eating and drinking, decreased urinating, increased fussiness, or ongoing fever please call your Pediatrician immediately. Please call 911 or return to the nearest emergency room immediately if your child has signs of respiratory distress or trouble breathing such as: Breathing faster than normal; Your child looks like he is working hard to breathe; Tugging between the ribs when breathing; Your childs nostrils flare (move in and out) with each breath; The lips turn pale, blue or dusky grey Increased cough or congestion.
Emergency Medicine
Pediatrics

PERCARN #01
Discussed with patients family that the area and type of injury do not warrant a CT scan of the head at this time. Explained the risks and benefits. PECARN Criteria reviewed. The patient will be closely monitored in the Emergency Department for any significant changes. The family agrees with the clinical plan.
Emergency Medicine
Pediatrics

Abdominal Exam Reassessment #01
The patient appears comfortable and states that pain is improved. Tolerating oral intake. Vital signs reviewed and are normal. On repeat physical exam, the abdomen is soft and nontender All diagnostics tests reviewed and discussed with the patient.
Emergency Medicine
Physical Exam

Motor Vehicle Accident Physical Exam #01
HEENT: Atraumatic. No battle's sign or raccoon eyes. MUSCULOSKELETAL: Spine--no deformity or step off, nontender along the cervical, thoracic, and lumbar spine. SKIN: No seatbelt sign NEUROLOGICAL: Alert and oriented, no focal deficits. Sensation and strength intact throughout. Gait normal.
Emergency Medicine
Physical Exam

Physical Exam #03
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, no stridor; Neck: supple, no meningismus; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Calves symmetric, nontender, no palpable cord; Skin: No rash, normal skin tone; Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact
Emergency Medicine
Physical Exam

Physical Exam #04 JG
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, no stridor; patent oropharynx w/o erythema or exudate, uvula midline Neck: supple, no meningismus; trachea midline; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Calves symmetric, nontender, no palpable cord; Skin: No rash, normal skin tone; no clubbing, no cyanosis, no edema Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact; memory intact, no apraxia, no agnosia.
Emergency Medicine
Physical Exam

Triage Physical Exam #01
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent; Neck: supple; Chest: Equal chest rise, non labored breathing; Skin: No visible rash, normal skin tone; Neuro: Alert and Oriented to person, place, and time; No focal deficit
Emergency Medicine
Physical Exam

Adult Protective Services
There is NO concern for any abuse/neglect or other adult protective services-related issues at this time (family members and/or collateral historians appear to be appropriately engaged, concerned, and acting in the best interests of and for the welfare of patient), although the need for such concern has been thoughtfully considered.
Emergency Medicine
Psychiatry

Alcohol Discharge JG #02
1) Please do not drink alcohol or ingest any mind-altering substances and drive or make important decisions. Please cut down on your substance use/abuse. 2) You were given information about substance use/abuse. Please review this literature. 3) If you have any worsening of symptoms please return to the ED immediately. 4) Please follow-up with your primary care doctor in the next 5-7 days for evaluation of symptoms.
Emergency Medicine
Psychiatry

Alcohol Reassessment JG #01
Patient seen and reassessed. Patient is AAOX3, NAD, able to ambulate, non-tremulous, and tolerating oral intake. VSS. Patient states that they feel safe going home and have a safe way to get home. Give copy of tests performed. Discussed need to cut down on substance intake, given literature.
Emergency Medicine
Psychiatry

Fit for Confinement
There are no acute medical issues requiring hospitalization. The patient does not appear to have an acute medical condition at the time of discharge that would preclude confinement. The patient should return for repeat evaluation should any new or worsening symptoms develop.
Emergency Medicine
Psychiatry

Intoxication Discharge #01
The patient is clinically sober. The patient is alert and oriented x 3, is clear and coherent in conversation and has a normal gait and shows no signs of acute intoxication. The patient is safe for discharge.
Emergency Medicine
Psychiatry

Medical Clearance for Psychiatry #01
Medical evaluation performed. There is no clinical evidence of intoxication or any acute medical problem requiring immediate intervention. Final disposition will be determined by psychiatrist.
Emergency Medicine
Psychiatry

Psychiatric ED HPI #01
{AGE}, {Domicile (in/with)}, {Employed (as) / on disability (for), {marital status}, {Ethnicity/nationality/culture}, {Gender}, {Caregiver status and location}, {Main psychiatric diagnosis},{psychiatric hospitalization # + most recent}, {Prior Suicide attempts}, {prior violence}, {prior arrests}, {Active substance use}, {Prior withdrawal/DTs}, {relevant PMH} {brought in by/referred by} presenting with / seeking, in the setting of
Emergency Medicine
Psychiatry

Psychiatric Medical Clearance #01
Exam benign. No e/o trauma, toxic ingestion, electrolyte abnormality, infection, or primary neurologic abnormality. Medically stable from emergency department perspective.
Emergency Medicine
Psychiatry

Psychiatry discharge #01
At present, protective factors outweigh the risk factors. The patient does not appear to be at imminent danger to self/ others at present, denies suicidal thoughts and will be referred to outpatient psychiatrist/ therapist.
Emergency Medicine
Psychiatry

Smoking Cessation #01
Due to patients current smoking history I had an extensive discussion lasting more than 3 minutes about the need to quit smoking. I consoled the patient of the various negative side effects of smoking including, but not limited to, the risk of developing COPD, Lung cancer, and other cardiac diseases. I strongly recommended that patient stops smoking and the patient was given various options of smoking cessation tools such as NRT's and other pharmacotherapies.
Emergency Medicine
Psychiatry

Asthma Discharge #02
You should return to the hospital if: you begin to develop worsening shortness of breath/difficulty breathing despite treatment with your prescribed medications, if you develop fevers for greater than 2 days, worsening cough, or for any other concerns with your breathing or any other problems. For more information on Asthma please visit the American College of Chest Physician's Website at: http://www.chestnet.org/Foundation/Patient-Education-Resources/Asthma
Emergency Medicine
Pulmonology

Asthma Discharge #04
Please follow up with your primary care doctor within 2 days. Please fill the prescription for prednisone and take as directed. Please use the albuterol inhaler, 2 puffs every 4-6 hours as needed for 2 days and then as needed after that. Remember, technique is important: shake the inhaler, insert into spacer, breath out fully, then pump the inhaler and take several slow deep breaths through the spacer aerochamber with your mouth. Always use the spacer aerochamber whenever you use the inhaler. Please take all of your other medications as previously prescribed. If you have any worsening wheezing, shortness of breath, chest pain, fever, chills return to the ED.
Emergency Medicine
Pulmonology

Asthma Discharge #05
Home Instructions: Take medicines as directed by your caregiver. Visit your PMD if: You have wheezing, shortness of breath, or a cough even if taking medicine to prevent attacks. You have thickening of sputum. Your sputum changes from clear or white to yellow, green, gray, or bloody. You have any problems that may be related to the medicines you are taking (such as a rash, itching, swelling, or trouble breathing). You are using a reliever medicine more than 23 times per week. Visit the ER if: You are short of breath even at rest or when doing very little physical activity. You develop difficulty eating, drinking, or talking due to asthma symptoms. You have chest pain or you feel that your heart is beating fast. You are lightheaded, dizzy, faint or have bluish lips or fingernails. You have a fever or persistent symptoms for more than 23 days or symptoms suddenly get worse. You seem to be getting worse and are unresponsive to treatment during an asthma attack.
Emergency Medicine
Pulmonology

Asthma Reassessment JG #01
Patient seen and reassessed. Discussed results w/ patient. Wheezing improved. Vital signs improved. Patient able to speak in full sentences. Repeat PEEK flow is XXX. Discussed the use of controller medications. Will dc home w/ PMD followup and strict return precautions.
Emergency Medicine
Pulmonology

Chest Tube #01
The indication for the chest tube was clinically XXX. After explaining the benefits and risks of the procedure consent (Verbal and/or Written) was obtained from the patient. The RIGHT/LEFT chest was prepped with betadine and draped in sterile fashion. Sterile technique including gown, mask, and gloves were used. The local anesthetic agent XXX was used to anesthetize the skin and pleural surface using a small caliber needle. A 1 cm incision was made using a scalpel over the 4th/5th rib in the anterior axillary line. The soft tissues were dissected using curved hemostats. The pleural cavity was pierced using a blunt curved clamp and the pleural cavity was entered. An XXX French chest tube was placed through the hole and slid posteriorly and cephalad. The chest tube was secured at XXX cm with silk suture. The chest tube was attached to a Pleura-vac container. A sterile occlusive dressing was applied. A postoperative chest x-ray showed the chest tube to be in good position. I was present for the entire procedure and there were no complications.
Emergency Medicine
Pulmonology

PERC #02
No history of DVT/PE/cancer, calf pain/swelling, hemoptysis, OCPs, or recent trauma/surgery/immobilization.
Emergency Medicine
Pulmonology

Pneumonia Discharge #01
Pneumonia is a lung infection that can cause a fever, cough, and trouble breathing. Please continue all antibiotics as directed until complete. Nutrition is important - eat small frequent meals. Get lots of rest and drink fluids. Call your Primary Care Doctor upon arrival home from the hospital and make a follow-up appointment in XXX days. If your cough worsens, you develop a fever greater than XXX, you develop shaking chills, a fast heartbeat, trouble breathing and/or feel you are are breathing much faster than usual, call your Primary Care Doctor or return to the ED. Make sure you wash your hands frequently.
Emergency Medicine
Pulmonology

Pulmonary Fibrosis Discharge #01
Pulmonary fibrosis is scarring of the lung air sacs that send oxygen to the blood which causes shortness of breath. Exact cause not known but happens more with active or former smokers, those with exposure to toxic chemicals or pollution, family history, & breathing certain types of dust at work over a long time. You can help the progression of the disease by quitting smoking, getting flu and pneumonia vaccines, using supplemental oxygen as necessary. Please take medications as directed.
Emergency Medicine
Pulmonology

Pulmonary Hypertension Discharge #01
Take all medicines as told by your caregiver. If you have problems with a prescribed medicine, talk to your caregiver. Do not stop taking it on your own. Do not smoke. Eat a healthy diet. Avoid a high salt diet. Talk to a dietician (food specialist) about foods you should eat. Stay as active as possible. Avoid high altitudes. Be careful when using a hot tub. A hot tub can lower your blood pressure. If you have pulmonary hypertension and are female of childbearing age, talk to your caregiver about using birth control pills or getting pregnant. SEEK IMMEDIATE MEDICAL CARE IF: You have severe shortness of breath. You develop chest pain or pressure. You cough up blood. You develop swelling of your feet or legs. You have a sudden increase in weight.
Emergency Medicine
Pulmonology

Smoking Cessation #01
Quitting smoking is the single most important thing you can do to improve your health. In the strongest terms, I recommend that you quit as soon as possible. You can contact your doctor for more help.
Emergency Medicine
Pulmonology

Chest X-ray Interpretation #01
Interpreted by ED Physician: CXR (1 view): no acute abnormality: no infiltrates, bones appear intact, cardiac silhouette within normal limits.
Emergency Medicine
Radiology

Chest Xray Interpretation #01
Interpreted by MD: _ x-ray, _ views Lungs clear, heart shadow normal, bony structures normal, no free air under diaphragm, no pneumothorax.
Emergency Medicine
Radiology

Abdominal Pain ROS #01
No evidence of pancreatitis, AAA, cholecystitis, choledocholithiasis, cholangitis, mesenteric ischemia, small bowel obstruction, diverticulitis, colitis, appendicitis, or pelvic etiology such as ovarian torsion, TOA, or ectopic pregnancy.
Emergency Medicine
Surgery

Chest Tube #02
Both verbal and written consent were obtained, patient informed of risks including pain, infection, bleeding, placement in the wrong location, respiratory failure and understands and accepts these risks. Patient placed in the supine position. The lateral chest wall was draped and prepped in a sterile manner using chlorhexidine and betadine and locally anesthetized using 10 mL of 1% lidocaine with epi. The space between the mid axillary line and the anterior axillary line, and above the 5th rib were targeted. Using sterile technique an incision was made at and parallel to the 5th rib, soft tissue was dissected using kelly clamp and tunneled through the intercostal muscles directly over the superior aspect of the rib, and using gentle pressure, the pleural cavity was entered. Cavity confirmed with palpation of digit, no liver palpated, no adhesions. A size **** chest tube was then inserted into the pleural cavity to a length of *****. Immediate chest tube output noted to be *****. Placement confirmed with condensation coinciding with the patients respiration. Secured to skin with 2-0 nylon, vaseline gauze, and taped to patient, and connected to drainage system. Patient tolerated procedure well, no complications. Placement confirmed by Xray.
Emergency Medicine
Surgery

Incision and Drainage of Abscess #02
XX year old with fluctuant erythematous indurated mass - likely an abscess. Lido anesthetic, betadeine prep, I+D, pack, Clinda, wound follow up.
Emergency Medicine
Surgery

Small Bowel Obstruction #01
XXX year old Male / Female with XXX days of diffuse abdominal pain presents to the emergency department. The patient has (+)/(-) nausea, (+)/(-) emesis for XXX hours (+)/(-) constipation since XXX. (+)/(-) hematochezia (+)/(-) fevers (+)/(-) chills (+)/(-) melena (+)/(-) diarrhea. CT scan confirms a small bowel obstruction with a transition point at XXX. An NGT was placed after which XXX ml of bilious fluid was suctioned from the GI tract.
Emergency Medicine
Surgery

Fall Negative Statement #01
_ yo MF presents transferred from _ s/p fall _ hours ago from _ feet, neg LOC GCS _ hemodynamically stable. Head CT negative for fracture, negative for intracranial bleed. Cervical spine CT negative for for fracture or dislocation. Chest CT/Xray negative for fracture, pneumothorax. Abdominal CT negative for intrabdominal bleeding, solid, or holo viscous injury. Plevic Xray negative for fracture. The patient is not on aspirin, plavix, Coumadin, or any other blood thinners.
Emergency Medicine
Trauma

FAST JG #01
A coronal plane of the right upper quadrant was obtained and was negative for anechoic fluid in the right chest, in Morrison's pouch, or the right paracolic gutter. suprapubic window was negative for free fluid posterior and lateral to the bladder. Next, a coronal plane of the left upper quadrant was obtained and was negative for anechoic fluid in the left chest, the splenorenal space, and the left paracolic gutter. ext, subcostal and parasternal long windows of the heart were negative for the presence of free fluid in the pericardial space. These images were captured on the internal hard drive for archival and quality assurance purposes.
Emergency Medicine
Trauma

Negative Trauma Statement
No evidence of skull fracture, intracranial bleed, dental trauma, cervical, thoracic, or vertebral fracture or subluxation, no suspicion of thoracic, abdominal, pelvic or extremity injury by exam.
Emergency Medicine
Trauma

Trauma Physical Exam #01
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI, No e/o ocular trauma; ENT: Airway patent, Oral and nasal within normal limits, no e/o septal hematoma, no e/o dental trauma; Neck: No midline cervical tenderness or deformity, no anterior mass or crepitus, trachea midline; Chest: Lungs clear to auscultation bilateral, no chest wall tenderness or crepitus; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding or rebound; Musculoskeletal: Extremities symmetric, nontender, and without deformity proximal and distal, no pain with axial loading; Skin: No rash, normal skin tone; no seatbelt sign at neck, chest, or abdomen; Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact; Back: No thoracic or lumbar midline tenderness or deformity
Emergency Medicine
Trauma

Trauma ROS #02
No e/o skull fracture, intracranial bleed, dental trauma, cervical, thoracic, or vertebral fracture or subluxation, no e/o of thoracic, abdominal, or pelvic injury.
Emergency Medicine
Trauma

Trauma ROS JG #01
On physical exam no battle sign appreciated, no nasal-septal hematoma, no clear leakage from ears, nose or eyes suggestive of CSF leakage. There is no bony stepoffs or deformities. The patient moves all extremities without difficulty.
Emergency Medicine
Trauma

Kidney Stone Discharge #01
Follow up with your primary doctor within 2-3 days. Follow up with a Urologist this week (we will give you a list of urologists, but make sure they accept your insurance). Please call as soon as possible for an appointment. We have sent a prescription for Flomax (0.4mg daily) to your pharmacy. Please pick up the medication as soon as possible and take as directed. Use Motrin (also called Ibuprofen or Advil) 400 mg every 6 hours as needed for pain. If you have any stomach discomfort while taking Motrin, you can use TUMS to help. All of these medications can be purchased without a prescription. Drink plenty of fluids, avoid caffeine & alcohol. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist. Any worsening pain, fever, chills, difficulty urinating, or any other concerns, please see your doctor immediately or return to Emergency Department right away.
Emergency Medicine
Urology

Kidney Stone Discharge JG #02
Please take 1 tablet of PERCOCET every 6 hours, as needed for SEVERE pain. Please do not drive or operate heavy machinery while on this medication because it can impair your judgement. This is a very addictive medication, do not take it unless you absolutely have to. Please take 400 mg of MOTRIN (also know as Advil or Ibuprofen) every 6 hours, as needed for MILD pain. Do not that this medication if you have any history of ulcers or kidney disease. Please take FLOMAX once a day at bed. This medication may make you sleepy. Please follow-up with UROLOGY in the next 2-3 days - you were give a referral list. Please bring your labs and imaging with you to your appointment.
Emergency Medicine
Urology

UTI Discharge #01
UTI Discharge: HOME CARE INSTRUCTIONS - you were prescribed antibiotics, take them exactly as your caregiver instructs you. Finish the medication even if you feel better! Drink enough water and fluids to keep your urine clear or pale yellow. Avoid caffeine, tea, and carbonated beverages - these can irritate your bladder. Empty your bladder often. Avoid holding urine for long periods of time. Empty your bladder before and after sexual intercourse. After a bowel movement, women should cleanse from front to back. Use each tissue only once. SEEK MEDICAL CARE IF: You have back pain. You develop a fever. Your symptoms do not begin to resolve within 3 days. SEEK IMMEDIATE MEDICAL CARE IF: You have severe back pain or lower abdominal pain. You develop chills. You have nausea or vomiting. You have continued burning or discomfort with urination.
Emergency Medicine
Urology

Abscess Discharge #01
You have had an abscess drained in the Emergency Department and you may have had packing placed in the wound to help the abscess continue to drain at home. Please do not remove the packing. You may shower with the packing in place - let the soapy water clean your wound, do not scrub at it. Keep your wound covered to prevent transmission of infection to other people. Follow up with your primary care physician or in the Emergency Department in XXX days for a wound check and/or packing removal. Return to the Emergency Department immediately if you develop any of the following symptoms: Fevers, Increased redness or swelling around where your abscess was, Increased pain, or Generalized weakness or vomiting
Emergency Medicine
Wound Care

Abscess Discharge #02
Please return to ED or your Primary Care Doctor in 2 days for a wound check and packing change. Keep the wound covered and dry as directed. Return to ED for any increased pain, redness, or fever.
Emergency Medicine
Wound Care

Abscess Discharge #03
Please return to ED or see your doctor in 2 days for wound recheck and/or packing change. Please Keep the wound covered and dry. Once a day: wash the wound with soap/water, apply bacitracin or neosporin and re-cover the wound. If you have any worsening of symptoms, including severe pain/swelling/numbness/changes in sensation/weakness, redness which expands more than it is right now or any other concerns please return to the ED immediately.
Emergency Medicine
Wound Care

Dermabond #01
The patient had a laceration that was XXX cm in length. The wound was irrigated and cleaned. No foreign bodies were appreciated. It was subsequently closed with Dermabond in 4 layers.
Emergency Medicine
Wound Care

Incision and Drainage of Abscess #01
Verbal consent were obtained. The indication for the procedure was clinical suspicion for an abscess. **Yes/No confirmation with an ultrasound was performed.** The region was anesthetized with **local anesthetic**. The most fluctuant portion of the abscess was incised with an **xx** blade scalpel. The abscess cavity of explored and evacuated, all loculations were broken up with a curved hemostat. The cavity was then packed with packing material and dressed with a clean gauze dressing. I was present for this entire procedure and there were no complications.
Emergency Medicine
Wound Care

Laceration Discharge #01
Follow up with your primary care doctor within 48-72 hours for a wound check. Keep sutures covered and dry for 24 hours then clean with soap and water daily - do not scrub. Apply bacitracin and cover with gauze. Return to ED for suture removal 7 days. Return to the ED for any increased pain, redness, streaking (red lines), swelling, fever or chills.
Emergency Medicine
Wound Care

Laceration Discharge JG #02
Keep the wound clean and as dry as possible. Do not immerse or soak the wound in water. This means no swimming, washing dishes (unless thick rubber gloves are used), baths, or hot tubs until the stitches are removed or after about two weeks if absorbable suture material was used. Leave original bandages on the wound for the first 24 hours. After this time, showering or rinsing is recommended, rather than bathing. the first day, remove old bandages and gently cleanse the wound with soap and water. Cleansing twice a day prevents buildup of debris and will result in easier suture removal.
Emergency Medicine
Wound Care

Laceration Repair #02
Verbal consent was obtained, and patient was provided with risks and alternatives to the procedure. Wound was copiously irrigated with ******tap/NS******, cleansed with chlorhexidine, and anesthetized with *****XXX mL of lidocaine****. Wound carefully explored and no foreign body, tendon injury, or nonviable tissue were noted. Using sterile technique ******XXX-0 suture/staples**** was used to reapproximate the wound. ****XXX interrupted-sutures were placed. Patient tolerated procedure well, no complications. Patient advised to look for and return for any signs of infection such as redness, swelling, discharge, or worsening pain. Patient advised to return for suture removal within ******7-10 days****.
Emergency Medicine
Wound Care

Splint #01
The patients {EXTREMITY} was splinted with XXX inches of Orthoglass. The patient was neurovascularly intact after the procedure. The patient tolerated the procedure well, all questions addressed and answered.
Emergency Medicine
Wound Care

Suture #01
The laceration was identified to be XXX cm in length and located at XXX. The laceration was cleansed with XXX and all debris was removed. Local anesthesia was obtained by injecting XXX at the laceration site. The laceration was then irrigated with XXX cc of high-pressure irrigation. The wound was explored and no foreign bodies were found. There were no tendon or nerve lacerations. The wound was closed with *** XXX suture type, number, and technique***. A sterile dressing was then applied and anticipatory guidance was provided.
Emergency Medicine
Wound Care

Suture Removal #01
Verbal consent was obtained. Wound well approximated, no erythema, induration, or discharge noted. *****XXX sutures***** completely removed in a sterile fashion. Patient tolerated procedure well, no complications. Patient advised to look for and return for any signs of infection such as redness, swelling, discharge, or worsening pain.
Emergency Medicine
Wound Care

Suture removal JG #01
AFTER the stiches are removed: Clean your wound as directed. Carefully wash your wound with soap and water. Pat the area dry with a clean towel. Protect your wound. Your wound can swell, bleed, or split open if it is stretched or bumped. You may need to wear a bandage that supports your wound until it is completely healed. Minimize your scar. Use sunblock if your wound is exposed to the sun. Apply it every day after the stitches are removed. This will help prevent skin discoloration.
Emergency Medicine
Wound Care

Wound Discharge #01
Wound dressed with topical Bacitracin and sterile gauze. Instructed to return tomorrow morning for a wound check- leave dressing until then. Afterwards apply Bacitracin OTC BID and do warm soaks BID. Strict instructions to return for worsening redness, swelling or pus.
Emergency Medicine
Wound Care

Abdominal Pain Discharge #01
Please return to the emergency department immediately should you feel worse in any way or have any of the following symptoms: increasing or different abdominal pain, persistent vomiting, fevers or shaking chills. Please return to the emergency department for a recheck in 8-12 hours if the pain is persistent or worse so we can re-evaluate you and ensure that you are not developing a problem that would require surgery or hospitalization.
Emergency Medicine

Abdominal Pain Discharge #02
On repeat examination prior to discharge, the patient has a soft abdomen with no peritoneal findings. The patient was able to tolerate oral intake. The patient was advised that even though there is no evidence of a surgical emergency at this time, sometimes this is not visible on ***IMAGING*** or in the labs early in a disease course and that if there is additional pain they are to return for repeat evaluation. The patient stated understanding of this, has decisional making capacity and is discharged in stable condition. The patient was instructed to return to the emergency department for re-evaluation in 8-12 hours and sooner if they feel worse in any way.
Emergency Medicine

Alcohol Intoxication
Patient demonstrates clinical evidence for alcohol intoxication. The patient admits to intentional heavy drinking of alcohol and denies fall or injury. The patient also denies drug use. Some of the history and physical exam is limited due to the state of intoxication. All clothes were removed, all parts of the body were evaluated and there is no evidence of acute trauma. The plan is to observe patient in the ED until clinical sobriety is reached and reassess history and physical examination.
Emergency Medicine

Allergic Reaction Discharge #01
Please follow-up with your primary doctor(s) within 2-3 days. Please avoid any known triggers of your allergies. We recommend you see an Allergist - we have given you a list of allergists (check with your insurance before making any appointments). You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. We have sent a prescription for an Epi-Pen to your pharmacy. Please pick it up as soon as possible. Always carry this with you. In the Emergency Department today, we spoke about how to use the Epi-Pen only in the event of a severe allergic reaction with trouble breathing or throat swelling. You must go to the hospital right away if you ever use the Epi-Pen. Remember that they expire every year so you should have your doctor write a new prescription yearly. We have sent a prescription for prednisone to your pharmacy. Please pick it up as soon as possible and use as directed (40mg once daily for 4 more days). Take Benadryl (also called diphenhydramine) 25mg every 6-8 hours as needed for further allergy symptoms (can be purchased without a prescription) - please note that Benadryl often causes drowsiness so please do not drive, make important decisions or operate machinery until you know how it will affect you. Please return to the Emergency Department right away if you have any worsening or new shortness of breath, changes in your voice, tightness/itching in your mouth/throat, swelling, severe hives, chest pain, high fever. There is a very small chance of a recurrence of the allergic reaction, typically in the next 24 hours. If you see the same symptoms (rash, trouble breathing, vomiting, etc) return, come back to the Emergency Department immediately.
Emergency Medicine

Ankle Injury Discharge #01
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Recommend orthopedic follow up within the week; a referral list was provided. Please keep the affected extremity elevated, rest it and please keep compression wrap on. Take Motrin 600 mg every 8 hours for pain, as needed, with food. Ambulate as tolerated using crutch assistance. If you experience any worsening pain, swelling, numbness, weakness please return to ER
Emergency Medicine

Antibiotic DC #02
Please fill the prescription for the antibiotics and take as directed. Please finish the entire course of medication as prescribed. Do not use any alcohol or grapefruit juice with any antibiotics.
Emergency Medicine

Cellulitis Discharge #02
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Rest and elevate affected area. Take Motrin 600mg every 8 hours with food for pain. Please take Antibiotics as directed. If you experience any worsening redness, swelling, streaking (red lines), fever or chills please return to ED
Emergency Medicine

Conscious Sedation #01
Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The indication for sedation were: XXX. The patient had been NPO for greater than 4 hours. Time out was completed. Respiratory therapy and nursing staff were present at bedside and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. The total time for the procedure was XXX minutes and I was present for the entire procedure and there were/were not complications.
Emergency Medicine

Constipation Discharge #01
Please follow up with your primary care doctor within 2-3 days, bring your results with you. For constipation we also recommend a diet high in fiber (beans, fruits, vegetables, whole grains). If the diet does not work then please take Docusate (also called colace) 100mg 1-2 times a day as needed. This medication is available over the counter. Return to the Emergency Department for any new or worsening symptoms.
Emergency Medicine

Drug Seeker #01
The patient is manifesting multiple drug seeking attributes. Prior medical records, if available, were reviewed. Discussed with the patient that opioid pain medication will not be given during the ED visit. Alternative analgesia is offered and REFUSED/ACCEPTED.
Emergency Medicine

Drunk Discharge #01
Please stop drinking to excess. Return to ED for seizures, shaking, confusion, intractable vomiting, blood in vomit or any other concerning symptoms. Please do not drink and drive.
Emergency Medicine

DVT Medical Decision Making #01
Leg swelling most worrisome for DVT, no evidence of arterial insufficiency DDx includes DVT, thrombophlebitis, edema (cardiac, renal, hepatic dz), trauma, lymphedema, baker's cyst. Will obtain lower extremity US to evaluate for DVT; we discussed with the patient that a repeat Lower Extremity US will be needed in 5-7days if US in ED is normal
Emergency Medicine

DVT Negative Discharge #01
Even though the ultrasound of your leg in the Emergency Department today did not find a clot, it is still important that you repeat the ultrasound in 5-7 days because of the very small chance that a clot was too small to see on today's ultrasound. Please follow up with your doctor(s) within the next 3 days, but seek medical care sooner if your symptoms persist or worsen. Please call as soon as possible for an appointment. If you cannot follow up with your doctor please return to the Emergency Department for any urgent issues. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. If you have any worsening of symptoms or any other concerns please see your doctor or return to the Emergency Department immediately. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist.
Emergency Medicine

ED Discharge #01
Discussed results and outcome of testing with the patient. The patient was advised to follow up with their primary care doctor within the next 24-48 hours and return to the Emergency Department for worsening symptoms or any other concerns. Patient given a phone number to follow up on the specific results of the tests performed today in the emergency department.
Emergency Medicine

ED Sign-out #01
The patient was signed out to the incoming physician. All decisions regarding the progression of care and interpretation of tests will be made at their discretion.
Emergency Medicine

Foreign Body #01
Wound explored for a foreign body in a sterile field. Copious irrigation was provided with no evidence of a foreign body. Discussed the potential of retained foreign body with patient and signs/symptoms that should prompt immediate return to the ED for reevaluation.
Emergency Medicine

Foreign Body #01
Wound explored for foreign body and copious irrigation provided with no evidence of FB. Discussed the potential of retained foreign body with the patient and signs/symptoms that should prompt the patient to immediately return to the ED for reevaluation.
Emergency Medicine

Head Injury Discharge #01
Follow up with your Primary Care Doctor within 48-72 hours. Rest, take Tylenol 650 mg 1 tab every 4-6 hours, as needed, for pain. If you experience any nausea, vomiting, worsening pain, dizziness or changes in vision return to ED.
Emergency Medicine

Lumbar Puncture #01
The indication for the procedure was rule out XXX. Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The patient was placed in the XXX position. The lumbar portion of the back was prepped with betadine and draped in sterile fashion. Sterile technique including gown, gloves, and mask were used. The skin over the L2-L4 vertebrae was anesthetized using 3 cc of 1% lidocaine without epinephrine. A 22 gauge spinal needle was used to enter the subarachnoid space and XXX cc of CSF spinal fluid was obtained. The opening pressure was. CSF samples were sent to the lab for xanthochromia, cell count, glucose, protein, gram stain, and culture. The needle was removed and the patient was instructed to lay flat for one hour to prevent the development of a post-dural headache. I was present for the entire procedure and there were no complications.
Emergency Medicine

Lumbar Puncture #02
A lumbar puncture was performed to rule-out Intracranial bleed vs Infection. The back was prepped and draped in sterile fashion. Landmarks were identified. The area was infiltrated with 1% Lidocaine. A (22) gauge spinal needle was inserted into the interspace between L4-L5. Approximately (3) mL of (clear) CSF was obtained and sent to the lab for further analysis. The needle was withdrawn and a bandage applied. The patient was instructed to lie flat after the procedure. There were no complications and the patient tolerated the procedure well.
Emergency Medicine

Meningitis Negative #01
Kernig and Brudzinski signs are negative, no petechiae, no photophobia, no dysarthria, no facial asymmetry, and no focal deficits. Very low clinical suspicion for meningitis.
Emergency Medicine

Midlevel Note #01
I performed a face to face evaluation of this patient and obtained an independent history and exam. I agree with the above history, physical exam and plan of the midlevel provider.
Emergency Medicine

Midlevel Note #02
Per institutional requirements, I have reviewed the chart, however was not consulted specifically or made aware of this patient by the above midlevel provider and did not personally evaluate, interact with, or disposition this patient on the day of their visit.
Emergency Medicine

Motor Vehicle Accident (MVA) #01
XXX year-old patient with no significant PMHx presents to the ED for {s/p car vs. car} MVA today. Pt was {restrained/unrestrained} {driver/front seat passenger/driver's side rear passenger} when XXX; {positive/negative} airbag deployment. Was able to ambulate after the collision. Denies head injury, LOC, dizziness, numbness/tingling, or any other injuries. Able to move all extremities without difficulty.
Emergency Medicine

Needlestick Medical Decision Making #01
I have reviewed the Chief Complaint, the HPI, the ROS, and have directly performed and confirmed the findings on the Physical Examination. I have reviewed the medical decision making with all providers, as applicable. The MOST LIKELY DIAGNOSIS at this time is: occupational exposure to blood, source patient unknown status for HCV, HBV and HIV. The list of differential diagnoses includes, but is not limited to, the following: possible infectious disease transmission, including, but not limited to, HIV, HBV and HCV. The likelihood of each of these diagnoses has been appropriately considered in the context of this patient's presentation and my evaluation. PLAN: (1) post-exposure prophylaxis protocol (2) supportive wound care measures, as warranted clinically (3) anticipatory guidance (4) observation and serial evaluations (5) outpatient followup with primary care physician/provider and EHS. I will continue to reevaluate the patient, including the results of all testing, and monitor response to therapy throughout the patient's course in the ED.
Emergency Medicine

NEXUS #01
The patient was ruled out for C-spine injury via NEXUS criteria.
Emergency Medicine

NEXUS #02
Because the patient is A&Ox3, has no focal neurologic deficits, no posterior midline c-spine tenderness to palpation, no evidence of intoxication and has no painful distracting injuries there is no need to obtain radiographic studies to evaluate the cervical spine.
Emergency Medicine

PERC #01
Risk factors for pulmonary embolism by PERC criteria: Age < 50, Pulse < 100, SaO2 > 94%, No unilateral leg swelling, No hemoptysis, No recent surgery, No prior PE or DVT history, No exogenous hormone use. Based on this criteria the patient is low/high risk by PERC.
Emergency Medicine

Reassessment JG #01
The patient was seen and reassessed. Patient symptomatically improved. AAOX3, NAD, VSS. Discussed test results w/ patient, given copy of results. Patient verbalized understanding of hospital course and outpatient plans, has decisional making capacity. Will follow-up with Primary care doctor in the next 1-2 days; patient will call for an appointment. Will return to the ED if there is any worsening of symptoms. Patient able to ambulate w/o difficulty, is tolerating PO intake.
Emergency Medicine

Smoker #01
The patient is an active smoker, smokes XXX ppd for XXX years. Health education about smoking hazards was provided and recommended to stop smoking.
Emergency Medicine

Suture wound check #01
Please follow up with your primary doctor (or come back to the ED) within 48-72 hours for wound check. Please keep sutures/staples covered & dry for 2 days, then clean with soap/water, apply bacitracin and cover the wound once daily. Return to ED for suture removal in XXX days. Any increased pain, redness, streaking (red lines), swelling, fever, chills please immediately return to ER.
Emergency Medicine

Syncope EKG Negative #01
There are no signs of ischemia, WPW, ARVD, long QT, HOCM or Brugada on the Emergency Department EKG.
Emergency Medicine

Transfer #01
The patient requires hospital admission. The patient has been stabilized to the best of this emergency department's capabilities. Given the patient's medical needs and in light of the patient's preferences, appropriate facilities for transfer were discussed and the decision has been made to transfer this patient to XXX Hospital. The receiving facility has the capacity as well as the capabilities to provide care for the patient. I contacted Dr. *** who has accepted the patient in transfer. EMTALA transfer paperwork has been completed. Patient has been informed and updated of their current clinical status. The patient has given consent for the transfer - the risks and benefits were explained and the patient verbalizes understanding. . The patient will be transported by ambulance.
Emergency Medicine

Viral Illness Discharge #01
Follow up with your Primary Care Doctor within 48-72 hours for further evaluation. Please rest and drink plenty of fluids to remain hydrated. Please wash your hands regularly. Please take Acetaminophen 650 mg every 6 hours for pain or temp greater than 100. If you have any worsening or continued fever, chills, weakness, nausea, vomiting, abdominal pain return to ED
Emergency Medicine

Diabetes DC #01
Make sure you get your HgA1c checked every three months. This test monitors the severity of your diabetes. If you take oral diabetes medications, check your blood glucose two times a day. If you take insulin, check your blood glucose before meals and at bedtime. It's important not to skip any meals. Keep a log of your blood glucose results and always take it with you to your doctor appointments. Keep a list of your current medications, including injectables, and bring this medication list with you to all your doctor appointments. If you have not seen your ophthalmologist this year please call for an appointment. Check your feet daily for redness, sores, or openings. If you develop these signs/symptoms do not self-treat. Please, follow-up with a podiatrist (foot doctor) or your primary care doctor. Low blood sugar (hypoglycemia) is defined as a blood sugar below 70mg/dl. Check your blood sugar if you feel signs/symptoms of hypoglycemia. If your blood sugar is below 70 take 15 grams of carbohydrates (ex 4 oz of apple juice, 3-4 glucose tablets, or 4-6 oz of regular soda) wait 15 minutes and repeat blood sugar to make sure it comes up above 70. If your blood sugar is above 70 and you are due for a meal, have a meal. If you are not due for a meal have a snack. This snack helps keeps your blood sugar at a safe range.
Endocrinology
Medicine

Diabetes Instructions #01
The patient has been instructed on how to monitor their blood sugar and maintain a consistent carbohydrate diet. The patient is instructed to check their feet daily for open wounds or sores, get their eyes checked once a year and teeth cleaned twice a year. The patient was given a glucometer, test strips and taught how to use these devices. The patient was told to keep a blood sugar diary. The patient was instructed to exercise daily - start slowly and increase their activity as their comfort level dictates.
Endocrinology
Nutrition

Lefort Post-op #01
Instructed patient to apply ice to face 20 min on and then 20 min off. Sign above patients head. Scissors/ wire cutter at a bedside as well as Yankuer. Instructed patient no straws, no spitting, no nose blowing, no sinus pressure, sneeze with mouth open .Will keep the head of the bed elevated at 30-degree angle at all times.
ENT
Nursing

Septoplasty Post-Op #01
Please do not consume hot or spicy food. Please cough and sneeze with mouth open. Please avoid nose blowing.
ENT
Plastic Surgery

Tonsillectomy Diet #01
Cool and warm liquids that are not irritating to the throat should be given for the first day or two. Avoid hot liquids. Avoid citrus juices and milk. Advance at your own pace starting with soft foods and advancing to a regular diet. Avoid rough and scratchy foods and foods that are difficult to chew for approximately 5 days. Avoid strenuous exercise and blowing of nose.
ENT
Surgery

Tonsillectomy Post-op #01
Avoid harsh gargling or tooth brushing. This can cause bleeding. Gently rinse your mouth as directed to remove blood and mucus. Your face and neck may be swollen or tender after surgery, Wrap a bag of crushed ice in a towel and place it on your neck as directed. Use a cool humidifier in your home to help moisten the air and soothe your throat. Your throat may be sore up to 2 weeks after surgery. Some ear and throat pain happens with any throat operation. You may have small or large amounts of bleeding from the surgery areas up to 7 days. Most bleeding happens within 24 hours after surgery. Large amounts of bleeding need to be treated right away. Contact the doctor if you feel weak, dizzy, or like you might faint when you sit up or stand, have back/ chest pain, or difficulty breathing.
ENT
Surgery

Ear Surgery Post-Op #01
For the first 2 weeks - sneeze with mouth open, do NOT blow nose, and avoid strenuous physical activity. Please keep soap and water out of the ear and keep it dry. Please do not stick Q-tips into the ear canal. Notify your physician if you have significant increase in vertigo.
ENT

Ulcerative colitis Discharge #01
Ulcerative Colitis Discharge HOME CARE INSTRUCTIONS: There is no cure for ulcerative colitis disease. The best treatment is frequent checkups with your primary care doctor and gastroenterologist. . Periodic reevaluation is important. Symptoms such as diarrhea can be controlled with medications. Avoid foods that have a laxative effect such as: fresh fruit and vegetables and dairy products. During flare-ups, you can rest your bowel by staying away from solid foods. Drink clear liquids frequently during the day. Electrolyte or rehydrating fluids are best. Your caregiver can help you with suggestions. Drink often to prevent dehydration. When diarrhea has cleared, eat smaller meals and more often. Avoid food additives and stimulants such as caffeine (coffee, tea, many sodas, or chocolate). Avoid dairy products. Enzyme supplements may help if you develop intolerance to a sugar in dairy products (lactose). Ask your caregiver or dietitian about specific dietary instructions. If you had surgery, be sure you understand your care instructions thoroughly, including proper care of any surgical wounds. Take any medications exactly as prescribed. If possible, avoid stresses that aggravate your condition. Exercise regularly. Follow your diet. Always get plenty of rest. SEEK MEDICAL CARE IF: Your symptoms fail to improve after a week or two of the new treatment. You experience continued weight loss. You have ongoing crampy digestion or loose bowels. You develop a new skin rash, skin sores, or eye problems. SEEK IMMEDIATE MEDICAL CARE IF: You have worsening of your symptoms or develop new symptoms. You have an oral temperature above XXX, not controlled by medicine. You develop bloody diarrhea. You have severe abdominal pain.
Gastroenterology
Emergency Medicine

Cirrhosis DC #01
Cirrhosis is scarring of the liver. Common causes include heavy alcohol use, hepatitis B or C, or fatty liver. PREVENTION: Please avoid alcohol, speak with your doctor before starting on any new medication, herbs, vitamins, or supplements which may cause more damage to the liver. TREATMENT: Treat the underlying cause, reduce blood pressure, consume a low-salt diet, please continue taking diuretics. You may require abdominal fluid drainage (paracentesis). Please obtain regular vaccinations to prevent common infections. SEEK MEDICAL CARE IF: If you develop abdominal or leg swelling, shortness of breath, bruising or bleeding easily, feeling full/bloated, too much or too little sleep, yellowing of the skin or the whites of your eye, sudden confusion, or coma.
Gastroenterology
Hepatology

Colitis DC #01
HOME CARE INSTRUCTIONS: Get plenty of rest. Drink enough water and fluids to keep your urine clear or pale yellow. Eat a well-balanced diet. Call your primary care doctor for follow-up as recommended. SEEK IMMEDIATE MEDICAL CARE IF: You develop chills. You develop a fever. You have extreme weakness, fainting, or dehydration. You have repeated vomiting. You develop severe abdominal pain or are passing bloody or tarry stools
Gastroenterology
Medicine

Gastritis DC #01
Call your health care provider if: You develop stomach pain that progressively gets worse or doesn't go away; If you vomit blood or have black bowel movements; If you are losing weight (without trying); Avoid: NSAIDs- (e.g. Aspirin, Advil, Ibuprofen Motrin, Naproxen, Aleve)' Avoid alcoholic beverages; Take all medications as prescribed.; Call your healthcare provider for a follow-up appointment within one week
Gastroenterology
Medicine

Bereavement #01
Educated family on bereavement counseling/support group(s) such as Social Work, Pastoral Care, and/or Registered Nurses to help with their loss.
General
Social Work

Coumadin #01
Please have your PT/INR levels checked on XXXX and again on XXXX and then weekly. Please have all blood work fax to XXXX and follow up with XXXX for any adjustments needed to your Coumadin (Warfarin) dosage.
Hem / Onc
Cardiology

Sickle Cell Discharge #01
Sickle cell anemia is when red blood cells are abnormal. The RBCs get stuck together and are unable to bring enough oxygen to your organs. Call your doctor if any signs of infection, swelling, nausea or vomiting. Avoid dehydration by drinking an adequate amount of fluids. Avoid stress. Avoid high altitude places and mountains where there is less oxygen. It is important to treat infections right away even in the middle of the night - call your doctor with any temperature higher than XXX. Keep your regular check up appointments with your doctor and follow his instructions carefully Keep up with your vaccinations to prevent certain infections Take medications as prescribed - you also will be on folic acid.
Hem / Onc
Emergency Medicine

Thrombocytopenia Discharge #01
HOME CARE INSTRUCTIONS: Check the skin and linings inside your mouth for bruising or bleeding as directed by your caregiver. Check your sputum, urine, and stool for blood as directed by your caregiver. Do not return to any activities that could cause bumps or bruises until your caregiver says it is okay. Take extra care not to cut yourself when shaving or when using scissors, needles, knives, and other tools. Take extra care not to burn yourself when ironing or cooking. Ask your caregiver if it is okay for you to drink alcohol. Only take over-the-counter or prescription medicines as directed by your caregiver. Notify all your caregivers, including dentists and eye doctors, about your condition. SEEK IMMEDIATE MEDICAL CARE IF: You develop active bleeding from anywhere in your body. You develop unexplained bruising or bleeding. You have blood in your sputum, urine, or stool.
Hem / Onc
Emergency Medicine

Coumadin DC #01
This medication is used to thin the blood, to prevent and treat blood clots. Take this medication daily as prescribed by your physician. Tell your Dentist, Surgeon, and other Doctors that you are on this drug. This medication requires PT/INR Blood work monitoring, please do not skip any outpatient appointments checking these levels.
Hem / Onc
Medicine

DVT DC #01
Please take your "blood thinners" as prescribed. Walking and light exercise is encouraged - please increase activity as tolerated. If you develop new leg pain, swelling, and/or redness contact your doctor. If you develop new chest pain with difficulty breathing, a rapid heart rate and/or a feeling like 'passing out' please call emergency services immediately.
Hem / Onc
Medicine

Myelodysplastic Syndrome Discharge #01
In Myelodysplastic Syndrome (MDS) the bone marrow does not work normally - it makes abnormal blood cells. There are different types of MDS so you need a bone marrow biopsy to tell this information. Call your doctor if you feel weak, tired, dizzy, trouble thinking clearly, trouble breathing, bruising or bleeding easily, or get infections more easily. Your doctor will decide what treatment you will need to control this disease - it may include blood transfusions, medication, &/or chemotherapy. It is important to visit your doctor as directed.
Hem / Onc
Medicine

DVT Education #01
Signs and symptoms of DVT and its prevention reviewed with the patient. Ambulation encouraged.
Hem / Onc

Bacterial Infection Discharge #01
Take all antibiotics as ordered. Call your Primary Care Doctor upon arrival home to make a follow-up appointment. If you develop fever, chills, malaise, or change in the mental status call your Primary Care Doctor or go to the Emergency Department. Nutrition is important, eat small frequent meals to help ensure you get adequate calories. Do not stay in bed all day - Increase your activity daily as tolerated.
Infectious Disease
Emergency Medicine

Clostridium Difficile DC #01
If you no longer have diarrhea you do not have to do anything special. Good hand washing is always important. If you still have diarrhea, you and your family members should follow these guidelines: Wash your hands before you eat and prepare food. Wash your hands well after you use the toilet. Wash your hands well before and after you care for a person with C. Difficile. Wear disposable gloves if you must handle stool. Clean the bathroom daily with disinfectant cleaner (diluted bleach). Put disposable waste, like diapers or other such items, into plastic bags. Tie the bags securely, and throw them out with the regular trash. If clothes are heavily soiled with stool, wash them separately in detergent and bleach. Clothes not soiled with stool can be washed with other clothing.
Infectious Disease
Medicine

Pradaxa #01
The medication Pradaxa/Dabigatran is used to "thin the blood" so clots will not form and to keep existing ones from getting bigger. This medication may cause you may bleed more easily. Be careful and avoid injury. Use a soft toothbrush and an electric razor. Take this medication daily. You may take this medication with food or water to prevent an upset stomach. If you miss a dose call your health care provider or pharmacist right away. Prior to any procedures please inform your physician, dentist or surgeon.
Medication
Cardiology

Xarelto #01
The medication Xarelto/Rivaroxaban is used to "thin the blood" so clots will not form and to keep existing ones from getting bigger. This medication may cause you may bleed more easily. Be careful and avoid injury. Use a soft toothbrush and an electric razor. Take this medication daily. You may take this medication with food to prevent an upset stomach. If you miss a dose call your health care provider or pharmacist right away. Prior to any procedures please inform your physician, dentist or surgeon.
Medication
Cardiology

Antibiotics DC #01
Take your medicine with a glass of water or food as indicated by your physician. Please take the medication as directed. DO NOT STOP taking them even if you start to feel better. Do not share your medication with other people. Do not use your medicine in the future for a different infection. Ask your physician about which side effects to watch for. Try not to miss any doses. If you miss a dose, take it as soon as possible
Medication
Infectious Disease

Ambien Administration #01
Ambien was administered as per physician orders and given with good effect. The patient is resting comfortably. Respirations even, unlabored. Will continue to monitor
Medication
Nursing

Colace #01
Take the medication COLACE (docusate) 100mg three times a day to prevent/help with constipation. Painkiller medications containing opioids can cause constipation.
Medication

AICD Discharge #01
Your AICD can sense and treat certain abnormal heart beats. If your AICD gives you a shock (you will probably feel it), let your doctor know so he/she can check the device & make changes in the device as needed or change your medication. Check your device as directed on a regular basis. Talk to your doctor about driving permission. Avoid electric or magnetic equipment. If you are not able to use metal detectors at airports, ask for hand security search. Tell any doctors or nurses that you have an AICD. You cannot have an MRI. You may want to get a medical alert bracelet indicating that you have an AICD. Follow directions your doctor gave you regarding arm movement & exercises, lifting, sling use. Always carry your AICD card in your wallet and remember who the manufactor is. It is important to know what brand of AICD you have in case of emergency.
Medicine
Cardiology

Angina Discharge #01
HOME CARE INSTRUCTIONS: Only take over-the-counter and prescription medicines as directed by your caregiver. Stay active or increase your exercise as directed by your caregiver. Limit strenuous activity as directed by your caregiver. Limit heavy lifting as directed by your caregiver. Maintain a healthy weight. Learn about and eat heart-healthy foods. Do not smoke. SEEK IMMEDIATE MEDICAL CARE IF: You experience the following symptoms: Chest, neck, deep shoulder, or arm pain or discomfort that lasts more than a few minutes. Chest, neck, deep shoulder, or arm pain or discomfort that goes away and comes back, repeatedly. Heavy sweating with discomfort, without a noticeable cause. Shortness of breath or difficulty breathing. Angina that does not get better after a few minutes of rest or after taking sublingual nitroglycerin. These can all be symptoms of a heart attack, which is a medical emergency! Get medical help at once. Call 911 immediately. Do not drive yourself to the hospital and do not wait to for your symptoms to go away.
Medicine
Cardiology

Atrial Fibrillation Discharge #01
Atrial fibrillation is a very most common heart rhythm problem. The condition puts you at risk for strokes and heart attacks. It helps if you control your blood pressure, not drink more than 1-2 alcohol drinks per day, cut down on caffeine, getting treatment for over active thyroid gland, and get regular exercise. Call your doctor if you feel your heart racing or beating unusually, chest tightness or pain, lightheaded, faint, shortness of breath especially with exercise. It is important to take your heart medication as prescribed. You may be on anticoagulation which is very important to take as directed - you may need blood work to monitor drug levels.
Medicine
Cardiology

Myocardial Infarction Discharge #01
Call your doctor if you have unusual chest pain, pressure, or discomfort, shortness of breath, nausea, vomiting, burping, heartburn, tingling upper body parts, sweating, cold, clammy skin, or racing heartbeat. Call 911 if you think you are having a heart attack. Take all cardiac medications as prescribed - notify your doctor if you have any side effects. Follow cardiac diet - avoid fatty & fried foods, don't eat too much red meat, eat lots of fruits & vegetables, and dairy products should be low fat. Please lose weight if you are overweight. Become more active with walking, gardening, or any other activity that gets you to moving.
Medicine
Cardiology

Patient Review #01
All available clinical, physical, laboratory, radiographic, electrocardiographic, metabolic, and hemodynamic data were reviewed and analyzed.
Medicine
Critical Care

Diabetes Education #03
You should limit yourself to 180 grams of carbohydrates daily to help lower your hemoglobin A1C to a goal of <7.0%. You should limit excessive intake of foods that are high in simple sugars such as sodas, candies, and large amounts of sweet fruits. You should also limit excessive intake of foods that are high in complex carbohydrates such as pasta, rice, and potatoes, all of which are high in starch - a complex carbohydrate. In order to further aide in dietary changes to manage your diabetes, you should maintain a food diary for one month and record the amount of carbohydrates in each meal or snack. This should be brought to your primary care doctors office and then further discussed. For more information about dietary recommendations you can visit the website for the National Diabetes Initiative at http://www.ndei.org/ADA-nutrition-guidelines-2013.aspx.
Medicine
Endocrinology

Hyperthyroidism Discharge #01
Hyperthyroidism is when your body makes TOO MUCH thyroid hormone. Call your doctor if you feel more anxious, irritable, trouble sleeping, trembling, sweating a lot, fast heartbeat, tired, weight loss, diarrhea, abnormal periods. Your doctor will monitor thyroid blood work regularly to monitor levels. It is important to take medications prescribed. Please take your medications as directed.
Medicine
Endocrinology

Hypothyroidism Discharge #01
Hypothyroidism is when you do not make enough thyroid hormone. Common signs & symptoms of low levels of thyroid hormone include but are not limited to: tired, getting cold easily, coarse or thin hair, constipation, shortness of breath, swelling, irregular periods. Your doctor will do thyroid hormone blood tests at least once a year to monitor if your medication dose is adequate. Please take your thyroid medicine as directed by your doctor & on empty stomach
Medicine
Endocrinology

Gastrointestinal Bleed Discharge #01
There are 2 common types of Gastrointestional (GI) Bleeds: UPPER GI Bleed and LOWER GI Bleed. UPPER GI Bleed affects the esophagus, stomach, and first part of the small intestine. LOWER GI Bleed affects the colon and rectum. If you have a LOWER GI Bleed notify your Health Care Provider if you are vomiting blood, or coffee ground vomitus, and bowel movements that look like black tar. If you have a LOWER GI Bleed notify your health care provider if you develop are bright red bloody bowel movements. Take your medications as prescribed by your Gastroenterologist. If you have had an Endoscopy or Colonoscopy, follow up with your Gastroenterologist for Pathology results. Avoid NSAIDs unless your Health Care Provider tells you that it is ok (Aspirin, Ibuprofen, Advil, Motrin, Aleve). Follow up with your Gastroenterologist within 1-2 weeks of discharge.
Medicine
Gastroenterology

Gastroparesis Discharge #01
Gastroparesis happens when the stomach takes too long to empty, so it causes nausea & vomiting and feeling full too soon after eating. It is common with diabetes and smoking marijuana. Call your doctor if you have severe abdominal pain, nausea or vomiting, bloating, feeling full too soon after eating, trouble eating, or weight loss. You can help yourself by eating small frequent meals during the day, put food through blender before eating it, cut down on foods with fats like cheese & fried foods, & cut down on foods wth a lot of fiber like fruits, vegetables, & beans If you have diabetes, it is important to keep blood sugars as close to normal as possible You may need to take liquid food supplements for adequate nutrition.
Medicine
Gastroenterology

GERD Discharge #01
HOME CARE INSTRUCTIONS: Change the factors that you can control. Ask your caregiver for guidance concerning weight loss, quitting smoking, and alcohol consumption. Avoid foods and drinks that make your symptoms worse, such as: Caffeine or alcoholic drinks. Chocolate. Peppermint or mint flavorings. Garlic and onions. Spicy foods. Citrus fruits, such as oranges, lemons, or limes. Tomato-based foods such as sauce, chili, salsa, and pizza. Fried and fatty foods. Avoid lying down for the 3 hours prior to your bedtime or prior to taking a nap. Eat small, frequent meals instead of large meals. Wear loose-fitting clothing. Do not wear anything tight around your waist that causes pressure on your stomach. Raise the head of your bed 6 to 8 inches with wood blocks to help you sleep. Extra pillows will not help. Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver. Do not take aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). SEEK IMMEDIATE MEDICAL CARE IF: You have pain in your arms, neck, jaw, teeth, or back. Your pain increases or changes in intensity or duration. You develop nausea, vomiting, or sweating (diaphoresis). You develop shortness of breath, or you faint. Your vomit is green, yellow, black, or looks like coffee grounds or blood. Your stool is red, bloody, or black. These symptoms could be signs of other problems, such as heart disease, gastric bleeding, or esophageal bleeding.
Medicine
Gastroenterology

Pancreatitis Discharge #01
Pancreatitis is a condition which causes severe belly pain, irritated, or swollen Pancreas. The two main causes are gallstones or alcohol abuse. Follow a low-fat diet (e.g. fried foods, desserts, whole milk dairy products, fatty meats) and avoid Alcohol. If you are prescribed antibiotics, complete the entire course. Follow up with your Gastroenterologist within XXX days of discharge.
Medicine
Gastroenterology

Iron Deficiency Anemia Discharge #01
Both hemoglobin (Hgb) and hematocrit (HcT) values are used to define anemia. These lab values are obtained from a complete blood count (CBC) test. This is performed at a caregiver's office. Iron is an essential part of hemoglobin. Without enough hemoglobin, anemia develops and the body does not get the right amount of oxygen. Iron deficiency anemia develops after the body has had a low level of iron for a long time. This is either caused by blood loss, not taking in or absorbing enough iron, or increased demands for iron (like pregnancy or rapid growth). Foods from animal origin such as beef, chicken, and pork, are good sources of iron. Be sure to have one of these foods at each meal. Vitamin C helps your body absorb iron. Foods rich in Vitamin C include citrus, bell pepper, strawberries, spinach, and cantaloupe. In some cases, iron supplements may be needed in order to correct the iron deficiency. In the case of poor absorption, extra iron may have to be given directly into the vein through a needle (intravenously).
Medicine
Hem / Onc

MRSA Discharge #01
To prevent the spread of MRSA do the following: Wash your hands Keep wounds that are draining or have pus covered with a clean dry bandage. Bandages or tape can be thrown in the regular garbage. Avoid sharing items such as towels, washcloths, razors, clothing, or uniforms that may have had contact with the infected wound or bandage. Wash sheets, towels, and clothes that become soiled with hot water and laundry detergent. Dry clothes in a hot dryer rather than air drying. This helps to kill the bacteria.
Medicine
Infectious Disease

Hyponatremia Discharge #01
Hyponatremia is when you have LOW levels of Sodium. Home care instructions: Only take medicines as directed by your caregiver. Many medicines can make hyponatremia worse. Discuss all your medicines with your caregiver. Carefully follow any recommended diet, including any fluid restrictions. You may be asked to repeat lab tests. Follow these directions. Avoid alcohol and recreational drugs. Seek Medical Care IF: You develop worsening nausea, fatigue, headache, confusion, or weakness. Your original hyponatremia symptoms return. You have problems following the recommended diet. SEEK IMMEDIATE MEDICAL CARE IF: You have a seizure. You faint. You have ongoing diarrhea or vomiting
Medicine
Nephrology

Obesity Discharge #01
HOME CARE INSTRUCTIONS: Exercise and perform physical activity as directed by your caregiver. To increase physical activity, try the following: Use stairs instead of elevators. Park farther away from store entrances. Garden, bike, or walk instead of watching television or using the computer. Eat healthily, low-calorie foods and drinks on a regular basis. Eat more fruits and vegetables. Use low-calorie cookbooks or take healthy cooking classes. Limit fast food, sweets, and processed snack foods. Eat smaller portions. Keep a daily journal of everything you eat. There are many free websites to help you with this. It may be helpful to measure your foods so you can determine if you are eating the correct portion sizes. Avoid drinking alcohol. Drink more water and drinks without calories. Take vitamins and supplements only as recommended by your caregiver. Weight-loss support groups, Registered Dieticians, counselors, and stress reduction education can also be very helpful. SEEK IMMEDIATE MEDICAL CARE IF: You have chest pain or tightness. You have trouble breathing or feel short of breath. You have weakness or leg numbness. You feel confused or have trouble talking. You have sudden changes in your vision.
Medicine
Nutrition

Lung Cancer Discharge #01
HOME CARE INSTRUCTIONS: If you smoke, stop! Take all medications as directed. Please keep all appointments with your caregiver and other specialists. Ask your caregiver if you should see a cancer specialist if that has not been arranged. If you require oxygen or breathing equipment, be sure you know how to use it and who to call with questions. Follow any special diet directions. If you have problems with appetite, ask your caregiver for help. SEEK MEDICAL CARE IF: You have had a surgical procedure are you are having trouble recovering. You have ongoing weight loss. You have decreased strength or energy past the point when your caregiver said you would feel better. You develop nausea or lightheadedness. You have pain that is not improving. SEEK IMMEDIATE MEDICAL CARE IF: You cough up clotted blood or bright red blood. Your pain is uncontrolled
Medicine
Pulmonology

Pleural Effusion Discharge #01
HOME CARE INSTRUCTIONS: Take any medicines exactly as prescribed. Please follow up with your Primary Care Doctor and/or Pulmonologist as directed. Monitor your exercise capacity (the amount of walking you can do before you get short of breath). Do not smoke - ask your Primary Care Doctor and/or Pulmonologist for help quitting. SEEK MEDICAL CARE IF: Your exercise capacity seems to get worse or does not improve with time. You do not recover from your illness. SEEK IMMEDIATE MEDICAL CARE IF: Shortness of breath or chest pain develops or gets worse. You have an oral temperature above XXX, not controlled by medicine. You develop a new cough, especially if the mucus (phlegm) is discolored.
Medicine
Pulmonology

Pulmonary Embolism Discharge #01
Take your anticoagulation as directed. Please follow up with your Primary Care Doctor within one week. Call for appointment. If you develop shortness of breath or if your shortness of breath worsens call your Primary Care Doctor or go to the Emergency Department.
Medicine
Pulmonology

SIADH Discharge #01
HOME CARE INSTRUCTIONS: Take medications as directed by your caregiver. Many medications can make hyponatremia worse. Be sure you tell your caregiver about all your medications. Carefully follow any recommended diet, including any fluid restriction. You may be asked to repeat lab tests. Be sure to follow these directions. Your caregiver may talk to you about the treatment of any underlying condition that caused the SIADH. SEEK MEDICAL CARE IF: You develop worsening nausea, fatigue, headache, confusion or weakness. You get your original hyponatremia symptoms again. You have problems following the diet recommended. SEEK IMMEDIATE MEDICAL CARE IF: You have shaking that you cannot control (seizure). You lose consciousness (black out). You have ongoing diarrhea or vomiting.
Nephrology
Emergency Medicine

Chronic Kidney Disease #01
Avoid taking: NSAIDs - (ex: Ibuprofen, Advil, Celebrex, Naprosyn) or nephrotoxic agents (e.g. intravenous contrast used in CT scans) these can damage the kidney. Please have your medications reviewed by your primary care doctor and have your medications renally adjusted. Blood pressure control is important.
Nephrology
Medicine

CT Dye #01
This patient was found to have an elevated creatinine and may be at risk for contrast induced nephropathy. Discussed risks/benefits with patient, agrees w/ scan. The patient will receive IV hydration prior to the CT scan and immediately after. Will continue to monitor.
Nephrology
Radiology

Coordination Exam #01
Coordination: Finger to nose dysmetria was not present. Heel-shin dysmetria was not present. Gait: normal Tandem gait, heel - toe walk
Neurology
Physical Exam

Cranial Nerve Exam #01
Cranial Nerves: Visual acuity intact bilaterally, visual fields full to confrontation, pupils equal round and reactive to light, extraocular motion intact, facial sensation intact symmetrically in V1-V3 bilaterally, face symmetrical, hearing was intact bilaterally, head turning and shoulder shrug symmetric and there was no tongue deviation with protrusion.
Neurology
Physical Exam

Mental Status Exam #01
Mental Status: AAOX4, fluent, attends b/l, memory intact, no apraxia, no agnosia.
Neurology
Physical Exam

Motor Exam #01
Motor: 5/5 strength in all extremities, normal tone, and bulk. Deep tendon reflexes: Biceps right 2+. Biceps left 2+ Patella right 2+. Patella left 2+.
Neurology
Physical Exam

Neuro Exam #01
Kernig and Brudzinski signs are negative, no petechiae, no photophobia, no dysarthria, no facial asymmetry, no focal deficits.
Neurology
Physical Exam

Sensation Exam #01
Sensory: intact to LT/PP/Vibr/Pos/Temp 4x.
Neurology
Physical Exam

Intracranial Hemorrhage Admit #01
[] Strict BP control goal <140/90 w/ Cardene drip; [] Repeat CTH in 24hrs or prn for worsening mental status or neuro exam; [] q2 neuro checks, vitals; [] hold aspirin, lovenox; [] TTE; [] Telemetry Monitoring; [] SCD's for DVT prophylaxis; [] MRI brain w/ and w/o cont.; [] HgA1c, Lipid profile
Neurology

Stroke Discharge #01
The patient was admitted to the {neurology floor, stroke service}. An extensive work up done including: MRI brain showing XXX and MRA of head and neck demonstrated XXX. Telemetry and TTE also showed XXX. Etiology of stroke XXX. Goal BP 140/90. Pt started on Aspirin 81 mg and Lipitor 80 mg daily. The patient was also seen and evaluated by PT/OT recommending XXX. The patient was seen by a speech and swallow recommending a XXX diet. The patient was also seen by speech language and pathology recommending XXX
Neurology

Spinal Precautions #01
The patient was educated on their spinal precautions including no lifting greater than 8lbs, no twisting, and no bending. Patient verbalized understanding of these precautions. Patient maintained spinal precautions (no lifting greater than 8lbs, no twisting, and no bending) throughout session.
Neurosurgery
Physical Therapy

Arterial Line DC #01
Arterial line discontinued as per MD order. Pressure applied for 5 minutes, no bleeding or hematoma noted after removal. Pressure dressing applied. Neurovascularly intact at this time. Will reassess in 15 minutes.
Nursing
Critical Care

Central Line DC #01
Central line discontinued as per MD order. The patient tolerated the procedure well. Pressure held at the site by staff for 30 min. No signs of bleeding or hematoma noted; pressure dressing applied.
Nursing
Critical Care

Chest Tube Monitoring #01
The patients chest tube in place and draining to wall suction. Dressing changed, dry and intact. Petroleum gauze at the bedside. Incentive spirometer given to the patient. The patient is instructed on the use of spirometer and is able to demonstrate proper use. The patient is encouraged to continue use ten times per hour. Continuous pulse ox monitoring in place. The patient encouraged to ambulate three times or more per day.
Nursing
Critical Care

Discharge Instructions #01
A safe plan for discharge was discussed with the patient and family. The patient and family were agreeable to the plan of discharge and close outpatient follow-up was arranged. A copy of the test results performed while in the hospital were provided.
Nursing
General

IV Lock #01
IV Lock in place, flushed q2 hours, no signs of infiltration
Nursing
General

Nursing Receive #01
Pt received from outside unit and verbal sign-out obtained. In no apparent distress. Patient oriented to new surroundings, placed on monitor and vitals obtained. Will continue to monitor
Nursing
General

Nursing Sign-out #01
A verbal report given to receiving RN XXXX. The patient AAOx3, VSS and aware of bed assignment. Awaiting transport.
Nursing
General

Nursing Sign-out #02
Pt assigned a bed to outside unit. A verbal report was endorsed to floor RN. Pt stable for transport; patient and/or family made aware of transfer. The chart was placed in with the charge RN.
Nursing
General

Overnight #01
Vital signs stable throughout the night, medication regimen continued. Patient slept comfortably throughout the night. Frequent rounding was provided and safety was maintained. Will continue to monitor.
Nursing
General

Patient admission education #01
The patient will verbalize understanding of their individual plan of care and safety measures. The patient will be able to verbalize the importance of calling for assistance if necessary before attempting to get-out-of-bed to help in preventing falls and/or injury. Call bell within reach.
Nursing
General

Reassess #01
No changes from previous assessment. Will continue to monitor
Nursing
General

Transfusion #01
(Product) given. Risks and benefits of transfusion explained to the patient. Patient verbalized understanding of risks and benefits, has decisional making capacity. Patient aware of possible side effects. Consent placed in the chart. Vital signs stable. Second provider at bedside witnessed consent.
Nursing
Hem / Onc

Transfusion #02
1 unit PRODUCT transfusing. Pt verbalized understanding of signs and/or symptoms of an adverse reaction and need to report these immediately.
Nursing
Hem / Onc

Transfusion #03
Prior to transfusion the patients h/h was XXX. The patient received units of blood irradiated/filtered. Blood # and exp date #. The patient was premedicated with Tylenol and Benadryl. The patient tolerated well, no reaction noted.
Nursing
Hem / Onc

Subcutaneous Heparin Education #01
The patient was educated on subcutaneous heparin administration and how it is used to prevent the formation of blood clots. The patient verbalized understanding.
Nursing
Medication

Sepsis #01
The patient meets sepsis criteria. Two large bore IV's were placed. Fluids running. Two sets of blood cultures and a VBG were sent to the lab. See EMR for antibiotics given. Will continue to monitor closely.
Nursing
Medicine

Hemodialysis SP #01
The patient is not in any distress s/p hemodialysis. Vital signs stable.
Nursing
Nephrology

Pain #01
Evaluate pain using identified tools/self-report descriptions, physiologic and behavioral indicators. Establish with the patient what level of discomfort is acceptable that will allow for maximal function. Reassess pain at regular intervals using patient-appropriate scale and terminology
Nursing
Neurology

Diet #01
The patient tolerates the provided diet well without signs of choking or aspiration.
Nursing
Nutrition

Tube Feed #01
The patient tolerates tube feeds without signs of difficulty or aspiration
Nursing
Nutrition

Constant Observation #01
Upon arrival, the patient was placed on constant observation for XXXX at XXXX time. The patient was undressed, searched for potentially harmful devices and valuables were secured. The patient will be maintained in a safe environment and de-escalation techniques will be employed if patient becomes agitated. Will continue to monitor
Nursing
Psychiatry

Mittens Placed #01
Bilateral untied mittens in place to prevent pulling of lines. Alternative measures such as: increased safety checks done prior and during applying of untied mittens. Education provided to patient and family on the reason for untied mittens. Safety and comfort checks completed every 30 minutes. Assessment for release, skin and neurovascular checks completed every 2 hours and remain within defined limits.
Nursing
Psychiatry

NG Tube #01
NGT site intact, skin assessed and intact, no redness or skin breakdown, tube offloaded.
Nursing
Surgery

NPO #01
We explained to the patient not to eat or drink anything before the procedure (NPO). Explained the risks of any intake of food or liquids. Patient demonstrates understanding.
Nursing
Surgery

Toradol #01
You were given Toradol for pain management. Please DO Not take Motrin/Ibuprofen (NSAIDS) for the next 6 hours (Until _______)
Nursing
Toxicology

Tylenol #01
You were given 1000mg IV Tylenol for pain management. Please DO NOT take Tylenol for the next 6 hours.
Nursing
Toxicology

Foley #01
A Foley catheter was inserted using sterile technique, draining by gravity, and secured with StatLock. A second provider was present to confirm sterility.
Nursing
Urology

Foley DC #01
The patient is able to spontaneously void after Foley removal. Soft, non-distended bladder appreciated
Nursing
Urology

Straight Cath #01
Straight catheterization was performed under sterile technique to obtain urine specimen from the patient. Two providers were present for the procedure. Pt tolerated the procedure well. Sterile specimen collected. UA and Culture sent.
Nursing
Urology

Incontinence #01
Patient monitored for incontinence. After each episode of incontinence the skin was cleaned with a skin cleanser, a skin barrier was applied, and one breathable underpad was placed.
Nursing
Wound Care

Skin #01
Skin integrity maintained. The patient is repositioned q2 hours and as needed.
Nursing
Wound Care

Bathing #01
The patient was bathed and skin care was provided. Oral care provided.
Nursing

Compression Stocking Education #01
The patient was educated on how sequential compression stocking are used to increase venous return for blood clot formation. The patient verbalized understanding.
Nursing

Discharge instructions #01
The patient was given detailed instructions about activity and other precautions. Diet, weight loss, and therapeutic lifestyle changes discussed with the patient. Smoking cessation also discussed with patient, if applicable.
Nursing

Lab sent #01
Labs were drawn & sent; results reviewed. MD made aware of any gross abnormalities.
Nursing

Nursing Discharge #01
The patients peripheral IV was removed, no evidence of infiltration noted at discharge. Skin intact, VSS. The patient is not complaining of pain, discomfort, or distress at this time. The patient is discharged as per MD orders in stable condition. The patient was educated and provided with printed medication list & discharge instructions. The patient verbalized and indicated understanding. Safety maintained, awaiting escort off unit.
Nursing

PACU Discharge #01
The patient meets all criteria for discharge from PACU. The patient is awake/alert/VSS. The patient is medicated for discomfort. No vomiting. No bleeding appreciated. Skin pink warm dry and intact. IV intact, site benign. Afebrile. A verbal report was given to receiving RN. The patient is aware of transition to next unit.
Nursing

Shift Change - Nursing #01
The patient report endorsed to oncoming shift RN. No signs or symptoms of distress with the patient. MD are aware of patient assessment throughout the shift. All medications were given this shift with no adverse reaction noted. No issues at this time. Will continue to monitor.
Nursing

Cardiac Diet #01
Choose lean meats and poultry without skin and prepare them without added saturated and trans fat. Eat fish at least twice a week. Recent research shows that eating oily fish containing omega-3 fatty acids (for example, salmon, trout and herring) may help lower your risk of death from coronary artery disease. Select fat-free, 1 percent fat and low-fat dairy products. Cut back on foods containing partially hydrogenated vegetable oils to reduce trans fat in your diet. To lower cholesterol, reduce saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day, thats about 13 grams of saturated fat. Cut back on beverages and foods with added sugars. Choose and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,400 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further. If you drink alcohol, drink in moderation. That means one drink per day if youre a woman and two drinks per day if youre a man. Follow the American Heart Association recommendations when you eat out, and keep an eye on your portion sizes.
Nutrition
Cardiology

Heart Diet Education #01
Provided in-depth nutrition education on a Heart Healthy diet and reviewed written education handout (limiting saturated fats and cholesterol, avoiding salt, choosing whole grains ).
Nutrition
Cardiology

Warfarin Education #01
Discussed interaction between Vitamin K and Coumadin (Warfarin), the need to keep Vitamin K intake consistent and need to closely monitor their dietary intake. Educational material provided.
Nutrition
Cardiology

Diabetes Education #01
1) Assessed patients understanding about the link between diet and diabetes. 2) Discussed consistent carbohydrate intake, consuming protein rich foods with meals and snacks and limiting concentrated sweets and salts. 3) Reinforced importance of self-monitoring blood glucose levels.
Nutrition
Endocrinology

Diabetes Education #02
With the diagnosis of diabetes comes a strict diet regimen to help control blood sugars. This diet begins with watching carbohydrate consumption. Carbohydrates such as starches, fruits, dairy and starchy vegetables are the food groups that affect glucose levels in the body most profoundly. Carefully monitoring carbohydrate intake is the main component of the diabetic diet; eating three meals each day that are roughly equivalent in size can help control blood sugars. Regular exercise and weight control can help you manage your blood sugars as well. A registered dietitian can help you plan a diet customized to your individual needs.
Nutrition
Endocrinology

Diabetic Diet #02
A registered dietician can help you create a personalized plan for healthy eating. Make your calories count by choosing: 1. Healthy carbohydrates such as fruits, vegetables, whole grains, legumes (beans, peas and lentils) and low-fat dairy products. 2. Fiber-rich foods such as vegetables, fruits, nuts, legumes, whole-wheat flour and wheat bran. 3. Heart-healthy fish at least twice a week such as cod, tuna and halibut, which are low-fat options as well as salmon, mackerel, tuna, sardines and bluefish, which are rich in omega-3 fatty acids. Avoid fish with high levels of mercury. 4. "Good" fats such as avocados, almonds, pecans, walnuts, olives and canola, olive and peanut oils. Minimize foods with high saturated fats (beef, hot dogs, sausage and bacon), trans fats (processed snacks, baked goods, shortening and stick margarines), high cholesterol foods (high fat dairy products and animal proteins, fried food) and high sodium foods (fast food, many frozen foods, processed food).
Nutrition
Endocrinology

Steroid Education #01
Discussed side effects of steroids on blood glucose and recommended avoiding concentrated sweets and limiting salt intake while taking steroids
Nutrition
Endocrinology

RD Progress #01
-Monitor weight, lab values, po intake and GI tolerance; -RD to remain available for further nutrition interventions as indicated.
Nutrition
General

Kidney Education #01
Provided nutrition education for kidney health. Discussed limiting foods high in sodium, phosphorous, potassium, and monitoring protein intake. Patient verbalized understanding.
Nutrition
Nephrology

TPN #01
TPN infusing at ml/hr (gm amino acids, gm dextrose, ml 20%lipids) to provide kcal (kcal/kg, gm prot/kg per adm wt).
Nutrition
Nutrition

Postpartum Diabetes #01
The patient was educated on postpartum dietary recommendations, including the risk of development of Type 2 Diabetes Mellitus. We reinforced importance of Diabetes Mellitus screening 6-8 weeks postpartum.
Nutrition
Ob / Gyn

OB Epidural #01
Epidural site checked: no drainage, erythema or tenderness
Ob / Gyn
Anesthesia

OB Pain #01
Patients pain effectively managed with pain medications.
Ob / Gyn
Neurology

Breastfeeding #01
The infant latched onto the breast and demonstrated good suck and swallow.
Ob / Gyn
Nursing

Breastfeeding #02
The mother demonstrated the ability to breastfeed optimally. The mother demonstrated optimal positioning, recognition of rooting, proper tongue placement, sucking and swallowing.
Ob / Gyn
Nursing

Hyperbilirubinemia #01
Infant under phototherapy. Genitals covered with a diaper, eyes covered with an eyemask. Encourage q3hour feeds. Bilirubin levels checked as per MD order. Color, cry, activity, and elimination assessed and recorded.
Ob / Gyn
Nursing

Neonatal Bilirubin #01
Baby was noted to have a high cord bilirubin, so bilirubin was trended throughout the baby's stay and noted to be below phototherapy threshold. Discharge bilirubin was ____ at ____ hours of life, ____ zone.
Ob / Gyn
Nursing

Newborn #03
Infant feeding well, voiding and passing stool. Vital signs within normal limits. Safety checks of infant and mother done per policy and maintained.
Ob / Gyn
Nursing

Newborn #04
Infant vital signs stable on room air and is maintaining appropriate thermoregulation in the isolette. Tolerating all feedings with no residuals. Infant voiding and stooling appropriately. Will continue to monitor.
Ob / Gyn
Nursing

Postpartum Reassessment #01
VSS, tolerating food, ambulating and voiding without difficulty, pain well controlled with medications, breastfeeding and bonding well with newborn, peripheral IV in place and patent. will continue to monitor
Ob / Gyn
Nursing

Postpartum Reassessment #02
The patient's pain is being effectively managed with pain control medications. The patient is feeding her infant well and demonstrates an ability to care for infant and self.
Ob / Gyn
Nursing

Prepartum Reassessment #01
Vital signs stable, fetal movements present as per patient. Patient denies cramping, vaginal bleeding or leakage of fluids. The patient is resting comfortably. Will continue to monitor
Ob / Gyn
Nursing

Newborn #01
Active, alert, tolerating feedings, stooling and voiding. VSS. Newborn is bonding well with mother.
Ob / Gyn
Pediatrics

Newborn #02
Newborn out of transition period. VS within desired limits. Pink active and alert. Voiding and feeding
Ob / Gyn
Pediatrics

Pediatric Circumcision #01
Please apply bacitracin to penis tip with each diaper change or four times a day. Some bleeding is expected. If you notice an excessive amount of bleeding or the infant seems to be excessive pain please contact your physician.
Ob / Gyn
Pediatrics

C-section #01
Infant delivered by cesarean section at XXX weeks, The patient and infant were received from L&D accompanied by L&D nurse via bassinette. Infant placed under radiant warmer servo controlled, baby on blood glucose monitoring for SGA. The mother plans to breastfeed and baby will bond with mom. Infant's condition stable, skin pink and warm, tolerating feedings, voiding and passing stool. No acute distress and bonding with mom.
Ob / Gyn
Surgery

Newborn Discharge #01
Since admission to the newborn nursery. The baby has been feeding well, stooling, and making adequate wet diapers. Vitals have remained stable. Baby received routine care and passed auditory screening and received HBV. Bilirubin was ____ at ____ hours of life, which is ______ zone. Discharge weight was down _______ from birth weight. Stable for discharge to home after receiving routine newborn care education and instructions to schedule follow up pediatrician appointment.
Ob / Gyn

Nipple Shield #01
Nipple shield need/application/care demonstrated and written materials provided. Effective latch achieved and sustained with milk flow noted.
Ob / Gyn

Pelvic Rest #01
Place nothing in vagina, no intercourse, no tampons, no tub baths, no swimming, no hot-tubs no douching until cleared by your medical doctor.
Ob / Gyn

Eye-surgery Post-op #01
No heavy lifting of straining, this can increase your intra-ocular pressure. Please leave the eye guard in place and keep soap and water out of eye. Do not remove dressing. You were given a Lens implant identification card - please take care of this, make a copy, and bring it with you to doctor appointments and ER visits. Please take care using steps and curbs as depth perception may be altered.
Ophthalmology
Nursing

Arthrocentesis #02
ARTHROCENTSIS PROCEDURE NOTE: Arthrocentesis Indication: Effusion / rule out septic joint Consent: the risks and benefits of arthrocentesis discussed with patient, including the risk of bleeding, infection, and technical failure. The risks of not performing the procedure, failure to diagnose septic joint with resultant systemic infection, discussed with the patient. The alternatives of performing the procedure also discussed. Written consent was obtained following the discussion. Universal Protocol: A timeout was performed and the correct patient and site were verified. The [ ] joint was prepped and draped in proper sterile fashion. The overlying skin was anesthetized with [ ] ml of 1% lidocaine. A [ ] gauge needle was used to aspirate fluid from the joint using appropriate anatomic landmarks. [ ] fluid was obtained from the joint. Approximately [ ] milliliters of fluid was obtained. The fluid was then sent to the lab for appropriate studies. The site was bandaged and no complications were noted. The patient tolerated the procedure well. Post-Procedure Diagnosis: Effusion Complications: None Specimens Removed: fluid only Prosthetic devices/implants: none.
Orthopedic Surgery
Emergency Medicine

Back Pain Discharge #02
HOME CARE INSTRUCTIONS: For many people, back pain returns. Since low back pain is rarely dangerous, it is often a condition that people can learn to manage on their own. Please remain active. It is stressful on the back to sit or stand in one place. Do not sit, drive, or stand in one place for more than 30 minutes at a time. Take short walks on level surfaces as soon as pain allows. Try to increase the length of time you walk each day. Do not stay in bed. Resting more than 1 or 2 days can delay your recovery. Do not avoid exercise or work. Your body is made to move. It is not dangerous to be active, even though your back may hurt. Your back will likely heal faster if you return to being active before your pain is gone. Only take over-the-counter or prescription medicines as directed by your caregiver. Over-the-counter medicines to reduce pain and inflammation are often the most helpful. Your caregiver may prescribe muscle relaxant drugs. These medicines help dull your pain so you can more quickly return to your normal activities and healthy exercise. Please avoid driving, operating heavy machinery or making important decisions while on this drug - it can cloud your judgment. Avoid feeling anxious or stressed. Stress increases muscle tension and can worsen back pain. It is important to recognize when you are anxious or stressed and learn ways to manage it. Exercise is a great option. SEEK MEDICAL CARE IF: You have pain that is not relieved with rest or medicine. You have pain that does not improve in 1 week. You have new symptoms. You are generally not feeling well. SEEK IMMEDIATE MEDICAL CARE IF: You have pain that radiates from your back into your legs. You develop new bowel or bladder control problems. You have unusual weakness or numbness in your arms or legs. You develop nausea or vomiting. You develop abdominal pain. You feel faint.
Orthopedic Surgery
Emergency Medicine

Bursitis Discharge #01
Bursitis is a condition that can cause pain or swelling next to a joint. Rest, cushion, and protect the area. Place an ice pack wrapped in a towel for relief. Take ibuprofen for pain and to decrease inflammation. Be sure to follow up with your primary care physician or orthopedic surgeon for re-evaluation in 2-3 days. RETURN TO THE EMERGENCY DEPARTMENT IMMEDIATELY FOR SEVERE PAIN THAT CANNOT BE CONTROLLED BY MEDICATION, SWELLING OR REDNESS, HIGH FEVER, OR FOR ANY OTHER CONCERN.
Orthopedic Surgery
Emergency Medicine

Radiculopathy Discharge #01
Radiculopathy is a pain, numbness, or tingling when nerves from spinal cord get pinched or damaged. Neck radiculopathy will affect one or both arms - lower back radiculopathy will affect the buttocks or leg. Call your doctor if you have new pain, numbness or tingling that spreads to your arms or legs. Radiculopathy can go away as nerves heal. You may be on pain medication, medication to relax muscles - please take your medications as directed. Please continue with physical therapy.
Orthopedic Surgery
Emergency Medicine

RICE Discharge #01
Rest, Ice (20 minutes at a time, 3 times a day), Compression (ACE wrap or splint), Elevation (above the heart). Follow up with your pediatrician in 1 week if symptoms persist, or with orthopedics if needed.
Orthopedic Surgery
Emergency Medicine

Pain Meds #01
Do not drive, operate heavy machinery and/or make important decisions while on these medications - they can impair your judgment.
Orthopedic Surgery
Neurology

Anterior Cervical Discectomy DC #01
Change bandage on neck daily with provided bandages. Change daily after shower. Cover neck incision daily with plastic cover & tape to keep dry. Wear foam neck-collar daily; you may take it off for meals & showering but keep on at night for sleep. No twisting/turning of head over the shoulders.
Orthopedic Surgery
Neurosurgery

Cervical Discectomy Discharge #01
The patient was admitted for elective anterior cervical discectomy and fusion. The postoperative course was uneventful. PT/OT Worked with patient for acute rehabilitation process. The pain was adequately controlled and patient is able to go home as the patient can accomplish ADL with help from family member at this time. The cervical collar was worn for comfort when out of bed.
Orthopedic Surgery
Neurosurgery

Cervical Laminectomy Discharge #01
The patient was admitted for posterior cervical decompression for (cervical stenosis/ cervical myelopathy), had posterior cervical laminectomy and fusion on XXX. The postoperative course was uneventful. The drain was pulled yesterday without incident and dry dressing placed. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go (home)/ (acute rehab). Medical comorbidities were well controlled during hospital stay.
Orthopedic Surgery
Neurosurgery

Kyphoplasty Discharge #01
The patient was admitted for pathologic, osteoporotic vertebral compression fracture, underwent kyphoplasty in the attempt to control pain and regain independent lifestyle. Vertebral kyphoplasty was performed on XXX. The postoperative course was uneventful. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go home as they can accomplish ADL with help from family members at this time. 
Orthopedic Surgery
Neurosurgery

Lumbar Discectomy Discharge #01
The patient was admitted for elective anterior lumbar discectomy and fusion on XXX. The postoperative course was uneventful. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go home as she can accomplish ADL with help from family member at this time.
Orthopedic Surgery
Neurosurgery

Lumbar Laminectomy Discharge #01
The patient was admitted for elective posterior lumbar laminectomy and fusion. The postoperative course was uneventful. Drain was self-removed by patient on post-op day #1. A dry dressing placed and the site was dry on post-op day #2. PT/OT worked with patient for acute rehabilitation process. The patient was started on ANTICOAGULATION for DVT prophylaxis and will continue for XXX weeks postoperatively. The pain is now adequately controlled and patient is able to go (home)/(acute rehab). Medical comorbidities were well controlled during hospital stay. A LSO brace was sized for the patient and provided for use when out of bed.
Orthopedic Surgery
Neurosurgery

Lumbar Laminectomy Discharge #02
Patient was admitted for elective posterior lumbar laminectomy on XXX for failed conservative treatment of persistent lower back pain, The hospital postoperative course was uneventful. The surgical dressing was changed and the drain was removed uneventfully. PT/OT worked with patient for gait training. A TLSO brace was fitted for patient and was used by the patient when out of bed for comfort. Pain was now adequately controlled and patient was discharged home in stable condition. Chronic medical conditions were treated during the hospital stay.
Orthopedic Surgery
Neurosurgery

Orthopedic Revision #01
Patient was admitted on XXX for reimplantation of total XXX hardware. Patient underwent the surgery without complication. Postoperatively, the patient was started on ANTICOAGULATION for DVT prophylaxis. Patient was seen by PT and medicine. Patient was WBAT of the XXX lower extremity. Patient was followed and blood counts were monitored. The patient's pain was treated and controlled using the standard pain management protocol. The wound was monitored. New dressings were applied as indicated. The intra-operative cultures were followed. Antibiotics were continued as medically indicated. The patient was discharged in stable condition.
Orthopedic Surgery
Neurosurgery

Thoracic Laminectomy Discharge #01
The patient was admitted for thoracic decompression, had posterior thoracic laminectomy on XXX. The postoperative course was uneventful. The drain was pulled on XXX without incident and dry dressing placed. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go (home)/(acute rehab). Medical comorbidities were well controlled during hospital stay.
Orthopedic Surgery
Neurosurgery

Ankle Exam #01
Ankle: skin intact; no deformity; no bony tenderness; dp and pt pulses 2+; capillary refill < 2 seconds; distal sensation intact; strength 5/5 flexion and extension foot/toes.
Orthopedic Surgery
Physical Exam

Back Exam #02
No midline spinal tenderness, no paraspinal tenderness. Strength 5/5 bilateral lower extremity. gross sensation intact bilaterally. deep tendon reflexes 2+ bilateral lower extremity. No clonus. Able to ambulate without difficulty.
Orthopedic Surgery
Physical Exam

Back Exam #03
The entire spine was palpated and nontender. No stepoffs or deformities noted. Skin overlying is intact and atraumatic. There is no paraspinal soft tissue tenderness to palpation. EHL/FHL bl is intact with 5/5 bl lower extremity strength. No saddle anesthesia is present. Normal sensory motor exam. 2+ normal bilateral DTRs LEs. Normal ambulation.
Orthopedic Surgery
Physical Exam

Back Exam #04
No cervical, thoracic or lumbosacral midline bony deformities, +rotation and flexion-extension of neck and truncal area intact.
Orthopedic Surgery
Physical Exam

Knee Exam #01
Quadriceps - No pathology appreciated; Quadriceps ad tendon - No pathology appreciated; Patella - No pathology appreciated; Patellar Tendon - No pathology appreciated; Joint line medial - No pathology appreciated; Joint line lateral - No pathology appreciated; McMurry - No pathology appreciated; Lachman - No pathology appreciated; Popliteal - No pathology appreciated; Neurovascular - No pathology appreciated
Orthopedic Surgery
Physical Exam

Knee Exam #02
Anterior, posterior drawer test and Lachman/Vulgus/Varus test are negative. No bony deformities, +knee flexion and extension intact, cap refill < 2 secs, pedal pulses intact.
Orthopedic Surgery
Physical Exam

Lower Extremity Exam #01
Proximal leg - wnl; Squeeze Test - wnl; Lateral Malleolus - wnl Medial; Malleolus - wnl; Deltoid -wnl; ATFL - wnl CFL -wnl; Achilles - wnl; Base 5th MT - wnl; Peroneals - wnl Neurovascularly intact
Orthopedic Surgery
Physical Exam

Neck Exam #01
The neck is nontender and without pain during active & passive range of motion Patient denies any numbness or weakness of upper or lower extremities. No step offs or deformities appreciated.
Orthopedic Surgery
Physical Exam

Sciatica Exam #01
There is lower lumbar area paraspinal muscle tenseness and tenderness radiating to buttock and lateral calf area. There is no cervical, thoracic or lumbar midline tenderness or bony deformities.
Orthopedic Surgery
Physical Exam

Upper Extremitiy Exam #01
The distal radial and ulnar pulses intact, cap refill < 2 seconds, full range of motion of arm +elbow flexion/extension/supination and pronation intact, +flexion and extension of all digits at DIP and PIP.
Orthopedic Surgery
Physical Exam

Upper Extremity Exam #01
Elbow - FROM, negative tenderness to palpation.; Scaphoid - negative prominence, snuffbox, axial load; DRUJ - negative for any pathology; TFCC - negative for any pathology; No swelling; No bruising
Orthopedic Surgery
Physical Exam

Activity #01
Ambulate as tolerated, increase your distance each time; Change your position every hour in order to minimize pain; No hot tubs, swimming pools or bathtubs until instructed by your surgeon; No driving or operating heavy machinery until cleared by your surgeon
Orthopedic Surgery
Physical Therapy

Hip Surgery Precautions #01
No straight leg raise; No external rotation of hip when extended-standing or lying flat; No hyperextension of hip when standing (kickback); Ice packs to hip for 30 min. every 3 hours & post physical therapy
Orthopedic Surgery
Physical Therapy

Hip Surgery Precautions #02
Do not bend your hip more than 90 degrees; Do not cross your legs or ankles when laying sitting or standing; Do not raise your operated leg up with your knee straight.; Do not bend over at your waist; Avoid sitting in low, soft chairs such as sofas and car seats. You should sit on a chair using firm pillows to raise the height of the seat.; Make sure your bed level is high, so that you maintain proper leg positioning when sitting on the side, or getting in or out; Avoid sitting in low, soft chairs, such as sofas, easy chairs etc.; When entering and traveling by car - Sit in the front passenger seat. Make sure that the car seat is all the way back and semi-reclined before entering; Do not allow your knees to come together when sitting or lying in bed; Do not take a tub bath yet; Do not resume driving until you have your surgeons permission.
Orthopedic Surgery
Physical Therapy

Home Discharge #01
Cleared by physical therapy for home discharge. Discharge instructions and medications have been completed and reviewed with the patient; patient has received a copy. Patient understands hospital course and outpatient instructions. Plan for office follow-up in XXXX days with Dr. XXXX for further evaluation.
Orthopedic Surgery
Physical Therapy

Rehab Discharge #01
Cleared by physical therapy for rehab discharge. Discharge instructions and medications have been completed and reviewed with the patient; patient has received a copy. Patient understands hospital course and outpatient instructions. Plan for office follow-up in XXXX days with Dr. XXXX for further evaluation.
Orthopedic Surgery
Physical Therapy

Shoulder Precautions #01
Keep shoulder elevated in sling at all times. Keep your shoulder close to your body and do not externally rotate shoulder in order to preserve rotator cuff repair. No heavy lifting/pushing/pulling/twisting/weight bearing with shoulder.
Orthopedic Surgery
Physical Therapy

Pre Surgical Testing #01
XXXX y/o XXXX presents for elective procedure XXXX by Dr. XXXX on XXXX day. Presurgical testing and clearance performed, placed in chart.
Orthopedic Surgery
Surgery

Open Reduction and Internal Fixation #01
The patient underwent an OPEN REDUCTION AND INTERNAL FIXATION on XXX for treatment of a XXX fracture. The patient received antibiotics YES/NO. The patient was medically cleared and underwent the procedure and had no intraoperative complications. Post-operatively, the patient was seen by OT/PT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per pain management protocol and the pain was appropriately controlled. The patient was NON-weight bearing. The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery
Trauma

Incision #01
Keep incision area clean and dry. You may shower post operative day X if no drainage present.
Orthopedic Surgery
Wound Care

Incision #02
Keep your incision clean and dry; You may use an ice pack for 20 minutes on and 20 minutes off to decrease pain and swelling.
Orthopedic Surgery
Wound Care

Anterior Cruciate Ligament Discharge #01
Post-Operative Instructions for Anterior Cruciate Ligament Reconstruction: Wound Care- You may remove the Ace Bandage the morning after surgery. Under the Ace is a layer of cotton wrap with small yellow strips. These too may all be removed the morning after surgery. Your wound is held together by layers of internal sutures and white plastic steri-strips. Do not remove these strips, they should stay on until you come for your post-op appointment in 3 weeks. You may take a shower, however, be sure to cover these strips with plastic wrap (ex. Saran wrap) so they do not get wet. You should see your physical therapist within the first 48 hours after surgery to begin therapy. The therapist should follow the prescription given to you upon discharge from the hospital as well as the protocol provided by our office when you booked the surgery. If you did not receive the protocol please call the office for a copy to be faxed to the therapist. If you have not arranged for physical therapy, please call the office for a list of some therapists or contact your insurance company for a list. Brace and Crutches- Upon discharge from the hospital, you will receive a brace and crutches. Be sure to use them when ambulating. You do not need to sleep in the brace. You may stop using both of these devices when you and your therapist feel you are safe without them (about 1-2 weeks). RICE Therapy: Keep your operated leg elevated with some pillows under the ankle. Ice the knee as much as possible for 20 minute intervals. It is important to always ice your knee after you exercise. Please call the office to schedule a follow-up appointment for 3 weeks. Things to look out for: Fever- a temperature of up to 101 degrees Fahrenheit is expected for up to the first two weeks after surgery. If this should occur, take Tylenol every four hours as needed to help reduce the fever. Call the office for fevers over 102 or those which persist and do not respond to Tylenol. Drainage- a small amount of drainage is expected for the first 72 hours. If you have excessive drainage following this period, or any thick or foul smelling drainage from the wound, call the office. Swelling- you may experience swelling for many weeks after the surgery, this is normal. During the first few weeks post-op, the swelling and bruising from the knee may gradually travel down to the calf, ankle, and foot. This may also cause bruising. This is to be expected as an effect of gravity. Wound- If your wound should open, notify the office immediately.
Orthopedic Surgery

Arthrodesis Discharge #01
The patient underwent Arthrodesis on XXXX. Postoperatively the patient received IV antibiotics and was made non-weight bearing. The patient received ANTICOAGULATION for DVT prophylaxis. The patient was seen and evaluated by PT/OT. The patient's pain was controlled. The patient was able to demonstrate how to ambulate without weight bearing on the affected extremity. The patient was instructed on the importance of elevation of the lower extremity. The surgical splint and dressing were changed. The lower extremity was placed into a well padded short leg cast. The patient was cleared by PT and discharged home in stable condition.
Orthopedic Surgery

Hip Discharge Precautions #01
TOTAL HIP PRECAUTIONS: Remember to continue all of the precautions for total hip replacement. Your surgeon will tell you when and if you can move beyond these limitations. Do not bend your hip more than 90 degrees. Do not cross your legs or ankles when lying, sitting, or standing. Do not raise your operated leg up with your knee straight. DO NOT bend over at your waist. Avoid sitting in low, soft chairs such as sofas and car seats. You should sit on a chair using firm pillows to raise the height of the seat. Make sure your bed level is high, so that you maintain proper leg positioning when sitting on the side, or getting in or out. Avoid sitting in low, soft chairs, such as sofas, easy chairs etc. When entering and traveling by car: Sit in the front passenger seat. Make sure that the car seat is all the way back and semi-reclined before entering. Do not allow your knees to come together when sitting or lying in bed. Do not take a tub bath yet. Do not resume driving until you have your surgeons permission.
Orthopedic Surgery

Hip Replacement Discharge #01
The patient underwent a TOTAL HIP REPLACEMENT on XXX. The patient received antibiotics post-operatively. The patient underwent the procedure and had no intraoperative complications. Post-operatively, the patient was seen by medicine and PT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per protocol and the pain was appropriately controlled. Patient was instructed by physical therapy The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery

Hip Surgery Discharge #01
{XXX} year old status post {HIP Surgery} without any intraoperative complications. The patient is doing well and stable for transfer to rehab. Pt is tolerating physical therapy: WBAT, TOTAL HIP PRECAUTIONS, gait training. Staples/sutures to be discharged on post-op day #10. The patient is on {XXX} for DVT prophylaxis but change to {XXX} when pt is discharged from rehab. Follow-up with {SURGEON} in 1 week
Orthopedic Surgery

Knee Arthroscopy Discharge #01
Patient underwent a knee arthroscopy on XXX. The patient will leave the applied dressing on for XXX days. The patient will then remove and apply new dressing daily. Showering and washing the wound may be started after postoperative day # XXX. The office will be contacted for any questions or concerns regarding the wound or other post-operative care. Physical therapy may be started as soon as ready. Pain medications will be taken as directed.
Orthopedic Surgery

Knee Replacement Discharge #01
The patient will be seen in the office in 2-3 weeks for wound check. Sutures/Staples/Tape will be removed at that time. Patient may shower after post-op day #3. The dressing is to be removed on XXX. If the dressing becomes soiled please change. The patient will contact the office if the wound becomes red, has increasing pain, develops bleeding or discharge, an injury occurs, or has other concerns. The patient will continue PT consistent with total knee replacement. The patient is FULL weight bearing. Elevation of the lower leg is recommended to reduce swelling.
Orthopedic Surgery

Knee Replacement Discharge #02
The patient underwent a TOTAL KNEE REPLACEMENT on XXX. The patient underwent the procedure and had no intraoperative complications. Postoperatively, the patient was seen by PT/OT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per protocol and the pain was appropriately controlled. The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery

Knee Surgery Discharge #01
{XXX} year old status post {Knee Surgery} without any intraoperative complications. The patient is doing well and stable for transfer to rehab. The patient is tolerating physical therapy: WBAT, gait training, CPM 0-45 degrees (advance as tolerated). Staples/sutures to be discharged on post-op day #10. Knee immobilizer on during transportation to rehab then discontinues when the patient is at rehab. The patient is on {XXX} for DVT prophylaxis but change to {XXX} when pt is discharged from rehab. Follow-up with {SURGEON} in 1 week.
Orthopedic Surgery

Orthopedic Procedure Check #01
Please check your toes/fingers for warmth, pink color, circulation and movement. If you have severe pain or discoloration of your extremity please contact your physician immediately.
Orthopedic Surgery

Orthopedic Surgery Discharge #01
The patient will be seen in the office between 2-3 weeks for wound check. Sutures/Staples/Tape will be removed at that time. Patient may shower after post-op day XXX. The dressing is to be removed on day # XXX. The patient will contact the office if the wound becomes red, has increasing pain, develops bleeding or discharge, an injury occurs, or has other concerns. The patient will continue Physical Therapy. The patient will take XXX for pain control and titrate according to prescription and patient needs.
Orthopedic Surgery

Orthopedic Surgery Discharge #02
Please call your Surgeon for follow-up appointment. Please call your Surgeon for any temperature greater than 101, any numbness or tingling in operated extremity, any redness or drainage from wound.
Orthopedic Surgery

Orthopedic Surgery Discharge #03
Activity: Weight Bearing as tolerated, Take short, frequent walks increasing the distance that you walk each day (as tolerated), Change your position every hour to decrease pain and stiffness. Continue the exercises taught to you by your physical therapist. No driving until cleared by the doctor. No tub baths, hot tubs, or swimming pools until instructed by your doctor. Do not squat down on the floor. Do not kneel or twist your knee. Avoid activities that place stress on your knee. Wound Care Keep your incision clean and dry. You may use an ice pack for 20 minutes on and 20 minutes off to decrease pain and swelling.
Orthopedic Surgery

Spine Surgery Discharge #01
{XXX} year old status post {Spinal Surgery} without any intraoperative complications. The patient is weight bear as tolerated, doing well and stable for transfer to rehab. The patient was instructed to call surgeon's office one week to make a follow-up appointment. D/C sutures/staples post-op day #14. NO ANTICOAGULATION, ASPIRIN OR NSAIDS FOR THIS PATIENT - RISK OF EPIDURAL
Orthopedic Surgery

Asthma Discharge #03
Please follow up with your pediatrician in 1-2 days. Continue Albuterol every 4 hours until you see you pediatrician. Continue Orapred for __ more days. Return to ED if patient has chest tightness, shortness of breath, difficulty talking, needs albuterol more frequently than every 4 hours or seems increasingly ill.
Pediatrics
Emergency Medicine

Asthma Discharge #06
Return to the hospital if your child is having difficulty breathing - breathing too fast, using neck muscles or belly to help with breathing. If your child is gasping for air or very distressed, or is turning blue around the mouth, call 911. Use albuterol every four hours until your child is seen by her pediatrician. She will need it every four hours while she recovers from this illness. Your pediatrician will give you instructions on how much longer to use it regularly and when you can go back to using it as needed. Take the Flovent twice daily as prescribed. This is your controller medication, so it needs to be taken every day whether you feel healthy or sick. It is to help prevent you from having an asthma attack.
Pediatrics
Emergency Medicine

Bronchiolitis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink approximately ___ oz. per day Use normal saline and gentile suctioning to clear mucus from the nose. Use a cool mist humidifier to decrease congestion. Monitor for fever, a temperature of 100.4 or higher, and if baby is older than 2 months control fever with Tylenol every 6 hours as needed. Follow up with your Pediatrician within ___ hours from discharge. If you are concerned and your baby develops worsening cough, faster or harder breathing, decreased drinking, decreased wet diapers, decreased activity, or worsening fever despite Tylenol use, please call your Pediatrician immediately. If your child has any of these symptoms: breathing VERY hard, breathing VERY fast, not drinking anything, not making wet diapers, or has any blue coloring please call 911 and return to the nearest emergency room immediately.
Pediatrics
Emergency Medicine

Infant Gastroenteritis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink about ___ oz. per day. Encourage clear liquids at first, then if tolerates can give breast milk/formula/milk/food. Do not dilute the formula. Make sure your child is making urine every 6 hours and has at least 4 wet diapers in 24 hours. Wash hands well, especially after contact -- this illness is very contagious as long as diarrhea or vomiting continues. Change diapers quickly after stool and use diaper ointment to keep skin from becoming irritated and a diaper rash from developing. Monitor for fever (Temperature of 100.4 or higher), if your child has a temperature and is older than 2 months you can give: Tylenol ____ mg every 6 hours as needed. Please follow up with your Pediatrician in ___ hours. If you have any concerns or your child has: continued vomiting, large or frequent diarrhea, decreased drinking, decreased wet diapers, dry mouth, no tears, is less active, ongoing fever if > 2 months old, then please call your Pediatrician immediately. If your child has any signs of dehydrations, stops drinking any fluids, has blood in the stool or vomit, is unable to hold down any liquids, is not urinating, fever in a baby < 2 months of age, acting ill or is difficult to awaken, or has severe abdominal pain, please call 911 or return to the nearest emergency room immediately.
Pediatrics
Emergency Medicine

Pediatric Abdominal Pain Discharge #01
Please follow up with your pediatrician in 1-2 days. Please continue with _______________. No limitations in diet. No limitations in activity, as tolerated. Please contact your pediatrician if your child experiences a return in abdominal pain, fever greater than 100.4, non-bloody diarrhea, decreased eating/drinking, decreased amount of urination or decreased activity Please seek immediate medical attention if your child begins to experience bloody diarrhea, severe abdominal pain, is not eating/drinking, is not urinating, is not responding appropriately to questions or commands/becomes difficult to awaken.
Pediatrics
Emergency Medicine

Pediatric Cellulitis Discharge #01
Routine Home Care as follows: Please continue to take your antibiotic as prescribed. Make sure your child drinks plenty of fluid. Your child should drink approximately ___ oz. of fluid in 24 hours. Please continue to mark the rash with a pen or marker and continue to take pictures of the rash/swelling until your are seen by your primary care doctor. Please follow up with your Pediatrician in _____ hours after discharge from the hospital. If your child has any concerning symptoms such as: decreased eating and drinking, decreased urinating, increased fussiness, worsening redness or swelling outside of the area previously marked, worsening pain, inability to ambulate or use the affected extremity, or ongoing fever please call your Pediatrician immediately. Please call 911 or return to the nearest emergency room if your child develops severe swelling in the affected area, difficulty breathing, or loss of sensation and feeling in the affected area.
Pediatrics
Emergency Medicine

Pediatric Fever Discharge #01
The patient was evaluated by myself and was noted to be completely nontoxic in appearance at time of discharge. The child was smiling, taking oral fluids without any difficulty and well appearing. There is no evidence of systemic toxicity at this time, but the child's parents were advised that the condition could change, and that if the child gets worse in any way to return to the emergency department immediately for reevaluation. They were specifically counselled in signs and symptoms of toxicity to look for: inability to tolerate oral fluids, lethargy, delayed capillary refill, alteration in mental status, or petechial rash.
Pediatrics
Emergency Medicine

Pediatric Gastroenteritis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink about ___ oz. per day. Encourage clear liquids at first then, if tolerates, can give milk/food. Note that after diarrhea, your child may have temporary lactose intolerance and may have worsening of diarrhea with dairy products. Make sure your child is making urine every 6 hours. Wash hands well, especially after contact - this illness is very contagious as long as diarrhea or vomiting continues. Please follow-up with your pediatrician within 1-2 days following discharge. If you have any concerns or your child has: continued vomiting, large or frequent diarrhea, decreased drinking, decreased urinating, dry mouth, decreased tears, is less active, ongoing fever, then please call your Pediatrician immediately. If your child has signs of dehydration such as crying without tears or no urine for >12 hours, or if your child stops drinking any fluids, if your child has blood in the stool or vomit, if your child is unable to hold down any liquids, acting ill (inconsolable or difficult to awaken), or your child has severe abdominal pain, please return to the emergency room or call 911.
Pediatrics
Emergency Medicine

Pediatric Seizure Discharge #01
Seizure Safety Precautions: Please do not permit your child to swim or bathe unattended as their seizures may put them at greater risk of drowning. If your child experiences a seizure, place them on a flat surface on the ground (somewhere he cannot fall) on their side. Do not put anything in their mouth. Call a physician. If a seizure lasts longer than 3 minutes, administer DIASTAT and call EMS immediately.
Pediatrics
Neurology

Birth History #01
Birth History - Born FT via NSVD, prenatal labs within normal limits, no complications with L&D, no NICU stay.
Pediatrics
Ob / Gyn

Infant Feeding Plan #01
Normal weight loss feeding care plan provided. Pt to feed every 2-3 hours, massage during feeds, do skin to skin as much as possible and minimize caloric expenditure.Infant to have a weight check with Pediatrician within 24 -48 hours.
Pediatrics
Ob / Gyn

Newborn Discharge #02
Routine Home Care Instructions: Please call us for help if you feel sad, blue or overwhelmed for more than a few days after discharge. Umbilical cord care: Please keep your baby's cord clean and dry (do not apply alcohol). Please keep your baby's diaper below the umbilical cord until it has fallen off (~10-14 days). Please do not submerge your baby in a bath until the cord has fallen off (sponge bath instead). Continue feeding child whenever baby shows signs of hunger - keep track of how often your baby feeds and how much and contact your pediatrician if your baby had a longer than typical period without feeding. Please contact your pediatrician and/or return to the hospital if you notice any of the following: Fever (T > 100.4), Reduced amount of wet diapers (< 5-6 per day) or no wet diaper in 12 hours, Increased fussiness, irritability, or crying inconsolably, Lethargy (excessively sleepy, difficult to arouse), Breathing difficulties (noisy breathing, increased work of breathing), Changes in the babys color (yellow, blue, pale, gray),Seizure or loss of consciousness.
Pediatrics
Ob / Gyn

Nursery Discharge #01
The parent(s) requested early discharge from the nursery. The risks were discussed, reasons to seek immediate medical attention were explained, and parents expressed understanding.
Pediatrics
Ob / Gyn

Pediatric Circumcision #02
Circumcision care was demonstrated to the mother with understanding. There was no bleeding, oozing or hematoma noted.
Pediatrics
Ob / Gyn

Poorly Feeding Infant #01
Poorly feeding infant discharge care plan provided. The infant will need to be offered both breasts with improved latch on every 2-3 hours. for 15 -20 minutes. Offer supplemental expressed breast milk and or formula every 2-3 hours, 15-30 ml. Establish and maintain breast pumping regimen every 3 hours.
Pediatrics
Ob / Gyn

Pediatric Sprain Discharge #01
Keep air cast on until you follow up with your pediatrician or orthopedist. Use crutches and no weight bearing for the next 2 days. Then, gradually begin to bear weight as tolerated. Elevate leg above your heart when not in use. Ice for 20 minutes at a time every hour as needed for pain for swelling. Motrin 3 times daily for pain and inflammation. Follow up with your pediatrician or orthopedist in 1 week if pain persists. Recommend physical therapy to strengthen muscles and prevent future injury.
Pediatrics
Orthopedic Surgery

Asthma Discharge #08
On the pediatric floor, the patient was progressively spaced from Q2h to Q4h albuterol treatments and continued on OraPRED for a total of 5 days. The patient will remain on Q4 until seen by a pediatrician within 24-48 hours of discharge.
Pediatrics
Pulmonology

Pediatric Dehydration #01
Please return to the emergency room for persistent vomiting, persistent diarrhea the inability to tolerate liquids, decreased urine output, lethargy, change in mental status or any other concerns.
Pediatrics

Pediatric Hypoglycemia Discharge #01
Your baby may get hungry more often, be sure to feed your baby whenever they are hungry. If your baby gets shaky or has a high pitched cry, be sure to make note how long since the last feed, feed as possible and contact your pediatrician regarding when and how to follow up.
Pediatrics

Back Exam #01
Back/Spine is non-tender. No pain with range of motion. No step-offs appreciated. Deep-tendon reflexes are +2/4, equal and without clonus. Sensory and motor are intact.
Physical Exam
Orthopedic Surgery

Physical Exam #01
Gen: WD, WN, in no acute distress.; HEENT: PERRLA, EOMI. oropharynx clear. ; Neck: Supple, no JVD/Bruit. No thyromegaly. ; Lungs: CTA B/L.; CV: RRR, S1 S2, No M/G/R.; Abd: Soft, ND, NT,No HSM, +BS. ;Ext: No clubbing, no cyanosis, no edema.; Neuro: A/Ox3. Cranial nerve intact. No focal deficit.
Physical Exam

Physical Exam #02
Gen: Alert, NAD; Head: NC, AT, PERRL, EOMI, normal lids/conjunctiva; ENT: B TM WNL, normal hearing, patent oropharynx without erythema/exudate, uvula midline; Neck: +supple, no tenderness/meningismus/JVD, +Trachea midline; Pulm: Bilateral BS, normal resp effort, no wheeze/stridor/retractions; CV: RRR, no M/R/G, +dist pulses; Abd: soft, NT/ND, no hepatosplenomegaly; MSK: no edema/erythema/cyanosis; Skin: no rash; Neuro: AAOx3, no sensory/motor deficits, CN 2-12 intact
Physical Exam

ROS Negative #01
No fever/chills, No headache, No photophobia/eye pain/changes in vision, No ear pain/sore throat/dysphagia, No chest pain/palpitations, No SOB/cough/wheeze/stridor, No abdominal pain, No N/V/D, No dysuria/frequency/discharge, No neck/back pain, No rash, No lower extremity edema, No changes in neurological status/function.
Physical Exam

Bed Mobility #01
In ## weeks, the patient will be able to perform rolling, scooting and bridging independently in bed in order to prevent the development of bed sores.
Physical Therapy

Bedroom Mobility #01
In ## weeks, the patient will be able to ambulate 200 feet w/ ## in order to walk from bedroom to front door to answer the doorbell.
Physical Therapy

Community Mobility #01
In ## weeks, the patient will be able to ambulate 1000 feet w/ ## in order to ambulate to public transportation for medical appointments.
Physical Therapy

Consult #01
Consult received from XXXX department and the chart was reviewed. The patient was received supine in bed, AAOx3 and NAD. The patient denies pain currently. Patient agreed to initial evaluation from Physical Therapist.
Physical Therapy

Crutches #01
The patient was provided with axillary crutches and was given a visual demonstration on safe and effective use. Patient was observed using crutches adequately.
Physical Therapy

Defer #01
The patient deferred Physical Therapy intervention at this time secondary to patient secondary to XXXXX. Patient was advised as to the benefits to participating and risks of not participating. Patient continued to refuse. Primary team notified and will continue to follow and re-attempt at later time
Physical Therapy

Discharge Independent #01
The patient presents without gross impairment and is independent with functional mobility. Therapeutic PT intervention is not indicated at this time. The patient will be d/c from the PT program at this time.
Physical Therapy

Discharge Independent #02
Patient functionally independent as per my evaluation. Cleared for discharge to home with no needs. Providers notified
Physical Therapy

Discharge Rehab #01
Patient is a good rehab candidate. PT will continue to follow and progress as tolerated.
Physical Therapy

Evaluation #01
The patient was seen for evaluation today. The patient was received supine in bed in NAD, AAOx3. The patient demonstrated independence with bed mobility activities and modified independence with sit to stand transfer. The patient demonstrated modified independence with ambulation.
Physical Therapy

No Stairs #01
Unable to safely assess patient on stairs at this time. The patient does not exhibit appropriate pre-requisite skills to safely negotiate unlevel surfaces due to XXXX which will put patient at significant risk for falls and injury.
Physical Therapy

Off Floor #01
The patient is off the floor at this time. Chart reviewed. PT will continue to follow patient and re-attempt at another time.
Physical Therapy

OOB #01
Patient advised that staff supervision/assistance is recommended for all out of bed activities including, but not limited to ambulation. Patient verbalized understanding and agreement.
Physical Therapy

Post Evaluation #02
Patient was left in bed/chair with call bell in reach. The patient was instructed to call RN for assistance as needed. PT to follow and assist patient until discharge home or rehab
Physical Therapy

Post evalutation #01
The patient was left seated in a chair, in NAD, all lines/devices intact and call bell within reach. Nursing staff made aware of patients status and participation in PT today.
Physical Therapy

Sitting #01
Patient performed multi-directional reaching activity in sitting position.
Physical Therapy

Standing #01
Patient performed multi-directional reaching activity in standing postion w/ bed behind pt for safety.
Physical Therapy

Unlimited mobility #01
In ## weeks, the patient will be able to ambulate 1000 feet w/ ## while carrying 2 small grocery bags in order to buy food from the local market.
Physical Therapy

Psychiatric ED Normal #01
Throughout the stay in the emergency department the patient was calm and cooperative, did not exhibit any aggression or agitation. The patient did not require any PRN medications or any physical restraints.
Psychiatry
Emergency Medicine

Suicide Risk Assessment #01
The patient is judged to be a low acute suicide risk and elevated chronic suicide risk. They deny current SI, has denied having any active SI since prior to recent hospitalization, they have no prior NSSIB, they are engaged in treatment and compliant with meds, mood is euthymic, they are hopeful and future-oriented with plans to start DBT program and eventually resume XXX and become a XXX, they have no active substance abuse, they have good social supports, and they have no access to firearms. Chronic risk factors include XXX prior suicide attempts, XXX personality disorder with chronic mood dysregulation and impulsivity, sexual orientation, and limited coping skills and poor frustration tolerance. Patient also with social stressor of turbulent interpersonal relationships. Risk will be minimized by participation in comprehensive outpatient psychiatric treatment.
Psychiatry
Emergency Medicine

Confusion DC #01
HOME CARE INSTRUCTIONS: What family and friends can do: To find out if someone is confused ask him or their name, age, and the date. If the person is unsure or answers incorrectly, he or she is confused. Always introduce yourself, no matter how well the person knows you. Often remind the person of his or her location. Place a calendar and clock near the confused person. Talk about current events and plans for the day. Try to keep the environment calm, quiet and peaceful. Make sure the patient keeps follow-up appointments with their physician. PREVENTION: Ways to prevent confusion: Avoid alcohol, Eat a balanced diet. Get enough sleep. Do not become isolated. Spend time with other people and make plans for your days. Keep a careful watch on your blood sugar levels if you are diabetic. SEEK IMMEDIATE MEDICAL CARE IF: You develop severe headaches, repeated vomiting, seizures, blackouts or slurred speech. There is increasing confusion, weakness, numbness, restlessness or personality changes. You develop a loss of balance, have marked dizziness, feel uncoordinated or fall. You have delusions, hallucinations or develop severe anxiety. Your family members think you need to be rechecked.
Psychiatry
Geriatrics

Dementia DC #01
HOME CARE INSTRUCTIONS: The care of individuals with dementia is varied and dependent upon the progression of the dementia. The following suggestions are intended for the person living with, or caring for, the person with dementia: Create a safe environment. Remove the locks on bathroom doors to prevent the person from accidentally locking himself or herself in. Use childproof latches on kitchen cabinets and any place where cleaning supplies, chemicals, or alcohol are kept. Use childproof covers in unused electrical outlets. Install childproof devices to keep doors and windows secured. Remove stove knobs or install safety knobs and an automatic shut-off on the stove. Lower the temperature on water heaters. Label medicines and keep them locked up. Secure knives, lighters, matches, power tools, and guns, and keep these items out of reach. Keep the house free from clutter. Remove rugs or anything that might contribute to a fall. Remove objects that might break and hurt the person. Make sure lighting is good, both inside and outside. Install grab rails as needed. Use a monitoring device to alert you to falls or other needs for help. Reduce confusion. Keep familiar objects and people around. Use night lights or dim lights at night. Label items or areas. Use reminders, notes, or directions for daily activities or tasks. Keep a simple, consistent routine for waking, meals, bathing, dressing, and bedtime. Create a calm, quiet environment. Place large clocks and calendars prominently. Display emergency numbers and home address near all telephones. Have a consistent nighttime routine. Ensure a regular walking or physical activity schedule. Involve the person in daily activities as much as possible. Limit napping during the day. Limit caffeine. Attend social events that stimulate rather than overwhelm the senses. Encourage good nutrition and hydration. Reduce distractions during mealtimes and snacks. Monitor chewing and swallowing ability. Continue with routine vision, hearing, dental, and medical screenings. Only give over-the-counter or prescription medicines as directed by the caregiver. Monitor driving abilities. Do not allow the person to drive when safe driving is no longer possible. Register with an identification program which could provide location assistance in the event of a missing person situation. SEEK MEDICAL CARE IF: New behavioral problems start such as moodiness, aggressiveness, or seeing things that are not there (hallucinations). Any new problem with brain function happens. This includes problems with balance, speech, or falling a lot. Problems with swallowing develop. Any symptoms of other illness happen. Small changes or worsening in any aspect of brain function can be a sign that the illness is getting worse. It can also be a sign of another medical illness such as infection. Seeing a caregiver right away is important. SEEK IMMEDIATE MEDICAL CARE IF: A fever develops. New or worsened confusion develops. New or worsened sleepiness develops. Staying awake becomes hard to do.
Psychiatry
Geriatrics

Dementia Discharge #03
There is no formal treatment for dementia, only symptom management. Behavioral disturbances usually worsen as the disease progresses. Patient at this time is not a candidate for inpatient psychiatric treatment as it would not alter the prognosis/symptoms of the illness. Patient cannot benefit from group therapy and/or individual therapy at this time due to inability to engage meaningfully with the environment. If family is unable to properly care for patient at home, pt would be best served in a nursing home where there is a high level of care, supervision, and often have dementia units where wandering/elopement risk and agitation are addressed.
Psychiatry
Geriatrics

Dementia Discharge #01
Upon careful evaluation of Patient's past psychiatric history, the course of illness including symptoms/severity/variation, as well as current symptomatology and clinical psychiatric presentation, it is with a high degree of clinical certainty that Patient has a primary diagnosis of dementia, advanced stage. Patient exhibits severe, multi-area cognitive deficits of aphasia, apraxia, agnosia, short-term memory loss, intermediate and long-term memory loss, episodic memory loss, personality changes, disorientation, diurnal variation, disorganized behavior consistent with advanced-stage degenerative dementia process. Subsequently, Patient cannot benefit from group therapy and /or individual therapy at this time. Summary: Patient is an AGE GENDER with multiple medical co-morbidities and advanced stage dementia (likely Alzheimer's subtype, late onset with delusions and behavioral disturbances) with unavoidable worsening symptoms as the neurodegenerative disease progresses. Patient's symptoms and behaviors will worsen as it is an unavoidable manifestation of the progressing neurodegenerative disease in its advancing stages. There is no formal treatment for dementia only symptom management. Patient at this time is not a candidate for inpatient psychiatric treatment as it would not alter the prognosis or symptoms of their illness; Patient cannot benefit from group therapy and /or individual therapy at this time due to inability to engage with their environment. Subsequently, Patient at this time would benefit from placement in an appropriate skilled nursing facility or nursing home. This was discussed with XXX. recommending social work involvement at this point as XXX DOES / DOES NOT feel comfortable / safe having him returned home.
Psychiatry
Neurology

Depression Symptoms ROS Negative #01
Patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry
Neurology

Depression #01
Patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry

Depression DC #01
SEEK IMMEDIATE CARE IF: You have thoughts about hurting yourself or others. You lose touch with reality (have psychotic symptoms). You are taking medicine for depression and have a serious side effect
Psychiatry

Depression Negative ROS #01
The patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry

Depression Positive ROS #01
The patient demonstrated depressive symptoms including persistent sad mood, hopelessness, helplessness, worthlessness, anhedonia, guilt feelings, difficulty concentrating, fatigue, decreased appetite, low motivation and difficulty falling asleep, lasting for XXX weeks.
Psychiatry

Manic #01
Patient denies manic symptoms including elevated mood, increased irritability, mood lability, distractibility, grandiosity, pressured speech, increase in goal-directed activity, or decreased need for sleep.
Psychiatry

Mood #01
The patient's mood is congruent, has normal range, intensity, and is non-labile
Psychiatry

Protective Factors #01
Protective factors include no suicide attempts, no violence history, medication compliance, no access to guns, no global insomnia, no substance abuse, supportive family, willingness to seek help, no suicidal ideation or homicidal ideation, hopefulness for future.
Psychiatry

Psychiatric negative history #01
The patient has not had any prior psychiatric visits, hospitalizations, medication trials or visits with a therapist or a counselor. No history of suicidality, suicidal attempts or self-injurious behavior in the past.
Psychiatry

Psychotic Symptoms Negative #01
The patient denies any psychotic symptoms including paranoia, ideas of reference, thought insertion/broadcasting, or auditory/visual/olfactory/tactile/gustatory hallucinations.
Psychiatry

Safer Discharge #01
Safety planning is done with patient and family. The family was advised to secure all sharps and medication bottles out of patient's reach at home. The family denies having any firearms at home. They were advised to call 911 or take the patient to the nearest ED if patient's behavior worsened or if there are any safety concerns. The family verbalized understanding.
Psychiatry

Suicide Risk Factors #01
Risk factors include: depression, anxiety symptoms, impulsivity, history of self- injurious behavior, prior suicidality, previous suicide attempts, prior hospitalizations, positive family history, history of substance abuse, multiple stressors, academic decline, absence of outpatient follow-up, poor insight into symptoms, poor reactivity to stressors, difficulty expressing emotions, low frustration tolerance, medication non-compliance.
Psychiatry

Smoking #01
Most former smokers quit without using one of the treatments. However, the following treatments are scientificy proven to be effective for smokers who want help to quit: 1) Brief help by a doctor (such as when a doctor takes 10 minutes or less to give a patient advice and assistance about quitting) 2) Individual, group, or telephone counseling 3) Behavioral therapies (such as training in problem solving) 4) Treatments with more person-to-person contact and more intensity (such as more or longer counseling sessions) 5) Programs to deliver treatments using mobile phones 6) Medications for quitting that have been found to be effective include the following: Nicotine replacement products; Over-the-counter (nicotine patch [which is also available by prescription], gum, lozenge); Prescription (nicotine patch, inhaler, nasal spray); Prescription non-nicotine medications: bupropion SR (Zyban), varenicline tartrate (Chantix)
Pulmonology
Medicine

Asthma Admit #01
The patient's asthma was diagnosed at age {XXX}. He/She has had {XXX} hospitalizations, {XXX} ICU stays, {XXX} intubations. He/She uses albuterol {XXX}. He/She is/is not on a controller medication. Precipitating factors include {XXX}. He/She has symptoms {XXX}days per week and {XXX}night-time awakenings per week. He/She has a history of eczema/allergies.
Pulmonology
Pediatrics

Asthma Discharge #01
Please seek immediate medical attention if the {you/your child} requires albuterol more than every four hours, is having difficulty breathing, pulling on ribs or neck, nasal flaring, unresponsive or more sleepy/drowsy than usual or for any other concerns.
Pulmonology
Pediatrics

Asthma Discharge #07
Return to the hospital if your child is having difficulty breathing. Signs of this include, but are not limited to: breathing too fast, using neck muscles or belly to help with breathing or nasal flaring. If your child is gasping for air, appears very distressed, or is turning blue around the mouth, call 911.
Pulmonology
Pediatrics

COPD DC #01
Call your primary care doctor upon arrival home to make a follow-up appointment within one week. Take all inhalers (e.g. Proventil) and steroids (e.g. Prednisone) as prescribed by your doctor. If your cough increases in frequency and severity and/or you have increased shortness of breath call your doctor If you develop fever, chills, night sweats, malaise, and/or change in mental status call your doctor. Increase your activity as tolerated. Do not stay in bed all day. Please do not smoke. Please continue using oxygen as home, if indicated.
Pulmonology
Respiratory

Extubation #01
Written order for extubation verified. The patient was identified by full name and birth date by the identification band. Present during the procedure were XXXX. The patient tolerated the procedure well and was placed on XXXX.
Pulmonology
Respiratory

Extubation #01
Orders to extubate. The patient is able to lift the head off the pillow. Extubated by respiratory therapy, able to expectorate secretions, voice soft but clear. 40% AFM in place O2 sat> 92%.
Pulmonology
Respiratory

Incentive Spirometer #01
The patient was importance and use of an incentive spirometer, coughing, and deep breathing exercises. A demonstration was provided. The patient verbalizes and demonstrates understanding.
Pulmonology
Respiratory

Incentive Spirometer #02
Incentive spirometer given to the patient and educated on proper use. The patient verbalized understanding and demonstrated appropriate use of incentive spirometer.
Pulmonology
Respiratory

Social Work #01
The social worker will continue to provide therapeutic and supportive counseling including concrete services and discharge planning. Referrals to outside agencies in the community will be made if necessary, and assessment will be ongoing until discharge from the hospital.
Social Work
Medicine

Cholecystitis DC #01
HOME CARE INSTRUCTIONS: Home care will depend on your treatment. If you were given antibiotics, take them as directed. Finish them even if you start to feel better. Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your doctor. Follow a low-fat diet until you see your caregiver again. Keep all follow-up visits as directed by your caregiver. SEEK IMMEDIATE MEDICAL CARE IF: Your pain is increasing and not controlled by medicines. Your pain moves to another part of your abdomen or to your back. You have a fever. You have nausea and vomiting
Surgery
Gastroenterology

Cholelithiasis DC #01
Gallstones are stones in the gallbladder that can block the gallbladder from draining bile. Please call your doctor if you develop severe stomach pain. This pain is usually located on the right side under your rib cage. This pain can radiate to the back or right shoulder. You can also develop nausea & vomiting. Rare complications that can occur include infections, gallbladder tears, and pancreas inflammation. You can help prevent gallstone formation by keeping a healthy weight - overweight people are more likely to get gallstones. However, losing weight too quickly can lead to gallstone formation so speak with your doctor before starting any dietary regimen.
Surgery
Gastroenterology

Diverticulitis #01
XXX year old Male / Female presents with XXX days of abdominal pain. The pain was sharp, crampy eventually with radiation to the XXX. The patients measured temp was XXX. The patient denies chills, diarrhea, dysuria, nausea or vomiting. The CT scan w/ oral and iv contrast showed diverticulitis with/without a collection.
Surgery
Gastroenterology

Small Bowel Obstruction Discharge #01
A bowel obstruction can occur when scar tissue forms inside the abdomen after a surgical procedure, causing a kink in the intestines. In some cases, food movement is totally blocked; with a partial bowel obstruction a limited amount of food can move through. Symptoms usually come on suddenly, and can be severe  acute pain in the abdomen with nausea or vomiting. Most people affected by a bowel obstruction are unable to pass gas or have a bowel movement, and may have a swollen abdomen. Infrequent bowel movements or hard stools usually do not indicate obstruction. If you have bowel obstruction symptoms it is important to see a doctor right away. Partial bowel obstruction may be treated in a hospital setting with a few days of bowel rest, a technique in which any remaining food is drained from a patients stomach and further food is eliminated. Intravenous fluids help you stay hydrated. If bowel rest does not work or bowel tissue begins to die due to the blockage, surgery may then be attempted. If you have a complete obstruction, immediate surgery is required.
Surgery
Gastroenterology

Reassess #01
The patient is stable - pain is well controlled, tolerating diet and voiding appropriately.
Surgery
General

Presurgical call #01
Pre-op call made by the provider. Spoke with patient XXXX. We advised on NPO status after XXXX time. Instructions given: no eye make-up, contacts, jewelry or piercings. Please bring a picture ID, a medical insurance card and to wear comfortable clothing. Please be aware an accompanying adult is required to provide a ride home. Please take any medication you were instructed to take in the morning with a small sip of water. Please review written instructions you received in Pre-Surgical Testing. Provider reviewed and answered any additional questions.
Surgery
Nursing

Laparoscopic Gas #01
You may experience some gas pains from residual carbon dioxide that may remain in your abdomen following the procedure. The pain usually presents as shoulder pain or sharp pain underneath your diaphragm. The pain is usually transient and will disappear in a day or two. It helps if you get up and move around while you are having this pain.
Surgery
Ob / Gyn

SAVI Procedure #01
Excision of breast mass through peri-areolar incision using Savi Scout marker localization. Biopsy clip & Savi Scout marker identified on intraoperative imaging. Additional breast tissue excised for margin. Hemostasis achieved. Local tissue rearranged using XXX sutures. Primary closure using XXX sutures w/ Steri-strips.
Surgery
Plastic Surgery

Interventional Radiology #01
Interventional radiology placed a XXX drain. Please follow up with interventional radiology to have your drain evaluated one week from discharge. Please call today to schedule an appointment (from one week from discharge date). Continue to empty and record the drain output daily as you have been taught.
Surgery
Radiology

Dressing #01
Patient's dressing is clean, dry, and intact. No drainage or odor present.
Surgery
Wound Care

Incision #01
Wash incisions with soap and water in shower daily, apply friction to release scab formation
Surgery
Wound Care

JP Drain #01
You will be discharged with Jackson-Pratt (JP) drains. You will need to empty them and record outputs accurately. You will be instructed by nursing staff on how to empty these drains. Please do not remove, manipulate or damage the JP drains. The JP drains will be removed in the office in a subsequent follow-up visit. Please bring a record of the JP drain output with you to the follow-up office visit.
Surgery
Wound Care

Steri-strips
Please allow sterile-strips to fall off on their own. It is ok to shower and rinse wound with warm soapy water. Do not scrub wound as this will disrupt the healing, instead pat dry. Please call the doctor immediately if you develop fever, chills, inability to tolerate liquid or food, diarrhea, nausea, vomiting or increased abdominal pain. Follow a regular diet. Do not drive or operate machinery while taking narcotic pain medication they can make your sleepy and impair your judgement.. Please follow up with your doctor within 1 week of discharge.
Surgery
Wound Care

Wound Care #01
Wound Care daily: Please pack the WOUND LOCATION openings with 1-inch sterile packing and then cover (including staples) with dry, sterile gauze and paper tape. Please contact your Surgeon if you develop any severe pain, copious and/or foul smelling discharge from the site, fevers or chills.
Surgery
Wound Care

Wound Vac Care #01
The wound vac dressing collapsed, adequate seal, suction maintained as per MDs order. Monitored q2h.
Surgery
Wound Care

Appendicitis #01
The patient presented with a clinical picture and objective findings, consistent with acute appendicitis. Medicar
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Surgery

Appendicitis #02
Based on clinical and objective findings the patient was found to have Acute Appendicitis and was admitted to the surgery service to undergo Laparoscopic Appendectomy. The patient tolerated the procedure well and was transferred to the floor in stable condition. On POD #1, the patients diet was advanced as tolerated and they were placed on oral pain medication. Once the patient was ambulating well, voiding without difficulty, and tolerating a full diet, they were found to be stable for discharge to home. The pain was well-controlled at the time of discharge. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Appendicitis #02
XXX year old Male / Female presents with XXX days of diffuse abdominal pain. The pain radiated to the RLQ +/- nausea +/- vomiting +/- fevers +/- chills +/- diarrhea +/- constipation +/- melena +/-hematochezia. WBC was XXX with shift. CT scan showed acute appendicitis.
Surgery

Bariatric Diet #01
Bariatric protocol diet (clear liquid diet for two days after surgery, then advance to full liquid diet with protein shakes). Start taking your vitamins when you return home. All medications must be in crushed/liquid/chewable/dissolvable form.
Surgery

Bariatric Surgery Hospital Course #01
{XXX} year old {XXX} with past medical history of morbid obesity and {XXX} with a BMI of {XXX} presents for elective bariatric surgery. Patient underwent {XXX} on {XXX}. Surgery was uncomplicated. On post-op day 01, clear liquid diet was initiated and tolerated by the patient. The patient was seen by a registered dietician prior to discharge. Patient ambulating, voiding, and stable for dc home on {XXX}. All questions addressed and answered, anticipatory guidance provided.
Surgery

Cardiothoracic Surgery Discharge #01
Take medications as prescribed. Follow up with your doctor as directed. Shower daily with mild soap & water, pat incisions dry. No washcloth on wounds. No oils/lotion/cream on incision sites. Increase activity slowly, as tolerated. No driving or heavy lifting for 4 weeks. Continue to use your spirometer & perform your deep breathing & coughing exercises as directed. Use red heart pillow under your seat belt for safety & use it when coughing for comfort. Eat a heart healthy diet low in salt, sugar & fat. Call your surgeon for fever over 101 degrees, pain not relieved by pain medication or if redness, swelling or oozing is noted @ incision sites. Call 911 for chest pain, shortness of breath, signs & symptoms of stroke.
Surgery

Cardiothoracic Surgery Discharge #02
Take medications as prescribed. Be sure to follow up with doctor appointments. If you should experience chest pain or shortness of breath call 911. Wash incision site daily with mild soap and water in the shower. Pat dry. Monitor site daily for symptoms of infection including redness, swelling, warmth, tenderness, or increased drainage. If you should experience any of these symptoms, or develop a fever, call your doctor.
Surgery

Cholecystitis #01
The patient presented with a clinical picture and objective findings, consistent with acute cholecystitis. Medical records were obtained and reviewed. The patient was educated on the clinical findings and the expected inpatient course. The patient agrees to admission and to be taken to OR for laparoscopic cholecystectomy..
Surgery

Cholecystitis #02
Based on clinical and objective findings the patient was found to have gallbladder pathology and admitted to the surgery service to undergo a Laparoscopic Cholecystectomy. The patient tolerated the procedure well and was transferred to the floor in stable condition. His diet was advanced, and he was placed on PO pain medication. Once he was ambulating well and voiding without difficulty, he was found to be stable for discharge to home. Pain was well controlled at the time of discharge and the patient was tolerating a full diet. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Cholecystitis #03
XXX year old Male / Female presents with XXX days presents with RUQ abdominal pain that began XXX days ago. +/- nausea +/- bilious emesis +/- hematochezia +/- fevers +/- chills +/- melena +/- diarrhea +/- constipation. The patient **does/does not** have a prior history of biliary colic. Laboratory studies show a WBC of _ and LFTs that **are / are not** elevated. Amylase and lipase **are / are not** within normal limits. An ultrasound shows gallstones with thickened gallbladder wall and pericholecystic fluid. The common bile duct was XXX cm in diameter. These results are consistent with acute cholecystitis.
Surgery

Diverticulitis #01
The patient was admitted with the diagnosis of diverticulitis and placed on bowel rest. IV antibiotics were started and serial abdominal exams were performed. Once the patient's abdominal pain began to improve, his diet was then restarted and slowly advanced as tolerated. As of hospital day XXX the patient's pain had resolved and he was tolerating a regular diet without nausea, vomiting, or abdominal pain. The patient was voiding well and ambulating without difficulty at the time of discharge. The patient will follow-up in the surgeons office in 1 week for checkup.
Surgery

Gastric Sleeve #01
M/F here a Same Day Admission for lap sleeve gastrectomy. The patient tolerated the procedure well. Post-operatively, the patients UGI was within normal limits. At time of discharge, the patient was tolerating a bariatric clear liquid diet, and the patients pain was controlled. Plan is to follow up with Dr. ____ in the office.
Surgery

Hernia #01
Based on clinical and objective findings the patient was found to have hernia pathology and was admitted to undergo bilateral inguinal hernia repair. The patient tolerated the procedure well and was transferred to the floor in stable condition. Their diet was advanced as tolerated and they were placed on oral pain medication. On POD #1, he was voiding without difficulty and ambulating well. Once his pain was well-controlled, he was found to be stable for discharge to home. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

JP Drain #02
Continue JP drain care as instructed. (Empty and record the JP drainage twice daily after discharge. Also, strip/milk the drain tubing each time to minimize clogging. Bring the recorded drain amounts to the office so that it can be reviewed by the physician.) Showers are permitted the day of discharge. The drains and the incision lines can get wet in the shower. Do not take a bath. Pin the drains to a bathrobe belt or string or a small towel draped over your neck in order that the drains do not dangle from your skin while in the shower. Keep incision sites and JP drain sites clean & dry after showering.
Surgery

Mastectomy #01
The patient is a XX YO female who was admitted to undergo LEFT/RIGHT Mastectomy. She tolerated the procedure well and was transferred to the floor in stable condition. Her diet was advanced as tolerated and she was placed on PO pain medication. On POD #1, she was ambulating well and voiding without difficulty. She was then found to be stable for discharge to home. Her pain was well-controlled at the time of discharge. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Surgery Discharge #01
The patient was admitted to XXX for surgery. The operation was uncomplicated and post-operative course was uneventful. The patient is tolerating a diet without nausea/vomiting, ambulating without difficulty, and voiding spontaneously with bowel function. The patients pain is well controlled on oral pain medication. The patient is deemed ready for discharge and will follow up with the surgeon.
Surgery

Surgery Discharge #01
The patient was brought to the operating room on XXXX for an operative procedure. Patient tolerated the procedure well with no known complications. Patient pain is well controlled, tolerating diet ambulating and voiding. All patient questions were addressed and answered. The patient is stable for discharge and is to follow up as an outpatient with his primary care doctor and primary surgeon.
Surgery

Surgery Discharge #02
The patient had XXX and required XXX performed in the operating room. Post-operatively the patient was sent to the PACU, the patient monitored and was hemodynamically stable and was subsequently sent to a surgical floor. The patient had daily wound care and was seen by physical therapy who recommended home/rehab. The patient's pain was controlled by IV pain medications and then transitioned to oral narcotics. The patient was advanced to regular diet and tolerated it well. Successful trial of void on post-op day XXX. Drains were removed prior to discharge. The patient was hemodynamically stable and was placed on home medications. The patient was told to follow up with Dr. XXX in 1-2 weeks and had no other issues.
Surgery

Trauma Activation #01
Level XXX Trauma Activation. The trauma team is at the bedside for evaluation. See trauma flow sheet for initial patient assessment and medications given.
Trauma
Emergency Medicine

Benign Prostatic Hypertrophy Discharge #01
You have an enlarged prostate gland which gets bigger as men get older - it is a very common problem. Call your doctor if you are urinating more frequently, have trouble starting to urinate, have a weak stream, urine leaking or dribbling, and feeling as though bladder is not empty after urination. Your doctor will monitor your prostate with a rectal exam as well as urine or blood testing. You can help yourself by reducing the amount of fluid you drink before going to bed, limiting the amount of alcohol & caffeine you drink. Please avoid cold & allergy medication that contain decongestants or antihistamines which make BPH symptoms worse. You can also "double void" by waiting a moment after urinating & trying again. Take your medication as prescribed.
Urology
Medicine

Foley Care #01
Please keep track of your hourly urine output. If you notice that your urine output has decreased for more than an hour please increase your water consumption. If this persists despite increases in your liquid intake or you develop and/or swelling in the suprapubic region (below your belly-button) please call your urologist. Do not allow the catheter to restrict your activity. Moving about and walking are important.
Urology
Nursing
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Lithotripsy Post-op #01
It is not uncommon to have some burning when you urinate or to even notice some stone fragments in your urine. This more than likely will pass in the next 24 hours. Please ensure adequate hydration and follow-up with your urologist as an outpatient.
Urology
Nursing

Urology Post-op #01
It is common to have blood in the urine after your procedure. It may be pink or red. If you have significant amount of clots in urine, difficulty urinating or inability to urinate inform your doctor immediately. Drink plenty of water. Do not perform strenuous activities or resume sexual activity until you are cleared by your doctor.
Urology
Nursing

Varicocele Post-Op #01
A small amount of blood is expected. Bruising (black and blue) scrotum and the penis is expected - this should resolve in a couple of weeks. Please removed the dressing and shower as instructed by your physician. No heavy lifting or sports until cleared by your physician. No sexual activity until cleared by your physician.
Urology
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PCA #01
The patient verbalizes and demonstrates understanding of proper use of PCA Pump (Patient Controlled Analgesia) for pain control.
Anesthesia
Nursing

Pacemaker Discharge #01
Your pacemaker is a device that can send an electrical signal to your heart when it is necessary. Please call your doctor if you feel dizzy, lightheaded, develop shortness of breath, are confused, more tired, or pass out (faint). Please follow up with your pacemaker doctor (Electrophysiologist) regularly to check your pacemaker. Your pacemaker battery usually will last 5 - 8 years. Please avoid certain electric or magnetic equipment. If you cannot walk through metal detector, ask for hand security search. Please consult your doctor before obtaining an MRI. Please follow directions that you received about arm use and mobility, driving, sex & sling use. Please consider obtaining an emergency medical bracelet telling people you have a pacemaker. Please tell any health care provider that you have a pacemaker.
Cardiology
Emergency Medicine

Syncope Discharge #01
HOME CARE INSTRUCTIONS: Have someone stay with you until you feel stable. Do not drive, operate machinery, or play sports until your caregiver says it is okay. Keep all follow-up appointments as directed by your caregiver. Lie down right away if you start feeling like you might faint. Breathe deeply and steadily. Wait until all the symptoms have passed.Drink enough fluids to keep your urine clear or pale yellow. If you are taking blood pressure or heart medicine, get up slowly, taking several minutes to sit and then stand. This can reduce dizziness. SEEK IMMEDIATE MEDICAL CARE IF: You have a severe headache. You have unusual pain in the chest, abdomen, or back. You are bleeding from the mouth or rectum, or you have a black or tarry stool. You have an irregular or very fast heartbeat. You have pain with breathing. You have repeated fainting or seizure-like jerking during an episode. You faint when sitting or lying down. You have confusion. You have difficulty walking. You have severe weakness. You have vision problems. If you fainted, call your local emergency services - do not drive yourself to the hospital.
Cardiology
Emergency Medicine

Hyperlipidemia Goals #01
In order to maintain a LDL<70 please eat a heart-healthy diet that is low in saturated fats and salt and includes whole grains, fruits, vegetables and lean protein; exercise regularly (consult with your physician or cardiologist first); maintain a heart healthy weight; if you smoke - quit and please continue to take your prescription medications as directed.
Cardiology
Endocrinology

Aortic Stenosis Discharge #01
Aortic stenosis is a condition when the aortic valve in the heart does not open fully so less blood flows out of the heart. Subsequently, the heart has to work harder than usual to pump the blood out of the heart to the rest of the body. You may have a heart murmur as a consequence. Please call your doctor with shortness of breath, dizziness or fainting, or chest pain, which will increase with physical activity. Your doctor will do echocardiograms to monitor the condition. Take your cardiac medications as directed to minimize cardiac workload - it is important to keep your blood pressure & cholesterol levels under control. Speak to your doctor about physical activity since this will depend on the severity of your condition.
Cardiology
Medicine

Cardiac Catheterization #01
The patient was objectively evaluated clinically and found to be at significant risk for coronary artery disease. The patient will undergo a left heart catheterization and possible percutaneous coronary intervention.
Cardiology
Medicine

Congestive Heart Failure (CHF) Discharge #02
Please take medications as prescribed. Follow up with your doctor as directed. Eat a heart healthy diet low in salt, sugar & fat. Limit sodium intake to 1500 - 2000 mg per day. Restrict your fluid intake to 1.5 - 2 quarts per day. Remember to weigh yourself every morning after voiding, record & report weight gain to your doctor as discussed. Call your doctor for swollen legs, ankles & feet, shortness of breath when you lie down or if you are coughing up pink and foamy or bloody sputum. Call 911 for chest pain, shortness of breath or for signs & symptoms of stroke.
Cardiology
Medicine

Congestive Heart Failure (CHF) Discharge #03
You should return to the hospital if you begin to have persistent chest pain especially if it radiates to the arm/jaw/back, shortness of breath or chest pain with exertion that is different than normal for you, worsening in any lower extremity edema (swelling), sudden onset of cold sweats with difficulty breathing, or for any other concerns. For more information on Congestive Heart Failure please visit the American Heart Association's Website at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp
Cardiology
Medicine

Congestive Heart Failure DC #01
HOME CARE INSTRUCTIONS: Weigh yourself daily. If you gain 3lbs in 3 days, or 5lbs in a week call your doctor. Do not eat or drink foods containing more than 2000mg of salt (sodium) in your diet every day. Call your physician if you have any increasing in swelling in your feet, ankles, and/or stomach. Take all of your medication as directed. If you become dizzy or chest pain please call your primary care doctor.
Cardiology
Medicine

Postcath #01
No heavy lifting, bending, straining, or unnecessary activity for 2 weeks. No driving for 2 days post procedure. You may shower 24 hours following the procedure but avoid bath-tubs, hot-tubs and/or swimming for 1 week. Check your groin site for bleeding and/or swelling daily following procedure; call your doctor immediately if it occurs or if you experience increased pain at the site.
Cardiology
Surgery

Postcath #02
No heavy lifting, driving, sex, tub baths, hot-tubs, swimming, or any activity that submerges the lower half of the body in water for 48 hours. Limited walking and stairs for 48 hours. Change the Band-Aid after 24 hours and every 24 hours after that. Keep the puncture site dry and covered with a Band-Aid until a scab forms. Observe the site frequently. If bleeding or a large lump (the size of a golf ball or bigger) occurs lie flat, apply continuous direct pressure just above the puncture site for at least 10 minutes, and notify your physician immediately. If the bleeding cannot be controlled, call 911 immediately for assistance. Notify your physician of pain, swelling or any drainage. Notify your physician immediately if coldness, numbness, discoloration or pain in your foot occurs.
Cardiology
Surgery

Angioplasty DC #01
Angioplasty or coronary stenting are procedures that open up narrowed/blocked coronary arteries in the heart. A stent is a tiny metal tube that helps open an artery in the heart muscle. Your doctor will instruct you when you can drive or resume usual physical activities You MUST take aspirin & another agent (e.g. Plavix) to help prevent clots inside the stent. It is VERY important to take these medications as directed UNLESS your cardiologist says it is OK to stop. The most common problems after coronary stenting are: bleeding, bruising, & soreness at the groin insertion site - you can use Tylenol for discomfort if not contraindicated. Call your doctor if you have chest pain, fever, pain, swelling, or redness where the groin insertion occurred
Cardiology

Cardiac Catheterization Consent #01
Cardiac catheterization w/ coronary angiogram and possible stent placement-consent obtained. The patient is competent, has the capacity, and understands risks and benefits of procedure (including possible alternatives). The risks which include, but are not limited to: bleeding, infection, CVA, PE, MI, arrhythmias, cardiac tamponade, CHF, retroperitoneal bleeding, pseudoaneurysm, other various vascular complications, kidney failure, allergic/contrast reactions, dissections or other various thromboembolic complications were explained to the patient in layman's terms. The patient clearly understands risks and decides to proceed with the procedure as planned.
Cardiology

Chest Pain #01
The patient's risk factors for ACS were reviewed as well as the EKG. The CXR assists in r/o Pneumonia, Pneumothorax, Esophageal Tears. The patient does not appear to have a Pulmonary Embolism based on the Wells Score and PERC rule and there is no apparent DVT. There are no signs of Pericarditis, Endocarditis, or Myocarditis based on risk factor analysis. There is no fever. There does not appear to be an Aortic Dissection either based on history, physical exam, and signs.
Cardiology

Chest Pain DC #01
HOME CARE INSTRUCTIONS: For the next few days, avoid physical activities that bring on chest pain. Continue physical activities as directed. Do not smoke and avoid drinking alcohol. Only take over-the-counter or prescription medicine for pain, discomfort, or fever as directed by your physician. Follow your physician's suggestions for further testing if your chest pain does not go away. Keep any follow-up appointments you made. If there is any problem keeping an appointment, please call to reschedule. SEEK MEDICAL CARE IF: You think you are having problems from the medicine you are taking. Read your medicine instructions carefully. You develop chest pain does not go away, even after treatment. SEEK IMMEDIATE MEDICAL CARE IF: You have increased chest pain or pain that spreads to your arm, neck, jaw, back, or abdomen. You develop shortness of breath, an increasing cough, or you start coughing up blood. You have severe back or abdominal pain, feel nauseous, or vomit You develop severe weakness, fainting, or chills. You have a fever. THESE ARE EMERGENCIES - Do not drive yourself to the hospital.
Cardiology

Coronary Artery Disease DC #01
Coronary artery disease is a condition where the arteries that supply the heart muscle get clogged with fatty deposits. This puts you at risk for heart damage and/or heart attack. PREVENTION: Lifestyle changes including, but not limited to, quitting smoking, if you smoke, eating lots of fruits, vegetables & low-fat dairy products, limiting your intake of meat and fatty foods. Please walk or participate in some form of physical activity at least 5 days a week and lose weight if you are overweight. Take your medications as prescribed. Make sure to keep appointments with your doctor for follow-up care. SEEK MEDICAL CARE: If you develop any chest pain, pressure, or discomfort; pain, tingling or discomfort in arms, back, neck, jaw, or stomach; shortness of breath, nausea, vomiting, burping or heartburn, sweating, cold and clammy skin, racing or abnormal heartbeat for more than 10 minutes or if they keep coming & going.
Cardiology

Hypertension Goals #01
Please eat a low salt, low cholesterol diet. Please exercise regularly and maintain a healthy body weight. Please take your blood pressure medication as prescribed.
Cardiology

Arterial Line Placement #01
An arterial line was placed under {ultrasound guidance/not under ultrasound guidance.} A-line flushes and has blood return. Positive SQ wave test and has good a waveform. Extremity has good coloration and cap refill < 2 seconds, sensation intact. Will continue to monitor.
Critical Care
Nursing

Cellulitis Discharge #01
Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
Dermatology
Infectious Disease

Intubation #01
The indication for the procedure is XXX. Respiratory therapy and nursing staff were present. The patient was monitored with continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen by non-rebreather mask and nasal cannula prior to intubation. The patient was sedated with *** IV MEDICATION*** and paralyzed with XXX mg of *** IV PARALYTIC*** . Once adequate sedation and paralysis were obtained a ***DIRECT LARYNGOSCOPY METHOD*** was used to directly visualize the vocal cords and an XXX endotracheal tube was placed through the cords, inflated and secured at XXX cm. Endotracheal tube placement was confirmed with capnography and bilateral breast sounds in the lungs. Post procedure chest X-ray showed the ETT to be in good position above the carina. I was present for the entire procedure and there were no complications.
Emergency Medicine
Anesthesia

Intubation #03
*** consent was obtained. Patient was preoxygenated, placed in appropriate position, paralyzed and sedated using ***. Using direct laryngoscopy, patient intubated using a MAC *** and a **** diameter ETT, placed to a depth of **** at the lips. There were no complications, patient tolerated procedure well, bilateral breath sounds were auscultated. Placement confirmed with positive end tidal CO2 color change and chest xray showing appropriate ETT placement.
Emergency Medicine
Anesthesia

Cardioversion #01
Consent (verbal and/or written) was obtained after the risks and benefits were discussed. The indication for the procedure was XXX. The patient had been NPO for greater than 4 hours. Respiratory therapy and nursing staff were present and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. The total time for the procedure was *** minutes and I was present for the entire procedure and there were/were not complications.
Emergency Medicine
Cardiology

Chest Pain Negative Statement
No evidence of ACS, pericarditis, myocarditis, pulmonary embolism, pneumothorax, pneumonia, Zoster, or esophageal perforation. Historically not abrupt in onset, tearing or ripping, pulses symmetric, no evidence of aortic dissection.
Emergency Medicine
Cardiology

Hypertension Admit #01
During the patients emergency department stay they were noted to have at least one blood pressure measure reading greater than 120/80. Due to this measurement I discussed with the admitting doctor the need to monitor the patients blood pressure and, if necessary, start the patient on medications to control the patients blood pressure.
Emergency Medicine
Cardiology

Hypertension Discharge #01
During the patients emergency department stay they were noted to have at least one blood pressure measure reading greater than 120/80. Due to this measurement I verbally educated the patient on hypertension and recommended they follow-up with their primary care doctor in the next 5-7 days for repeat measurement of their blood pressure and if it remains persistently elevated that their primary care doctor may start them on medications to control their blood pressure. I also recommended several lifestyle modifications (weight loss, dietary sodium restriction, increase physical activity and moderate alcohol consumption).
Emergency Medicine
Cardiology

Orthostatic Hypotension Discharge #01
Your blood pressure can drop when you change positions too fast especially from lying to standing. Please get up slowly first by put your feet on the floor and then wait five minutes while letting your feet dangle to prevent drop in blood pressure upon standing. Medications can cause worsened symptoms. Be sure to drink adequate fluids to keep hydrated , continue medications as ordered , report worsening symptoms to your primary care provider, use assistive devices to transfer and ambulate
Emergency Medicine
Cardiology

STEMI #01
The patient was immediately placed in a monitored bed, and IV was placed, oxygen was administered, and the EKG was evaluated. The ECG revealed an acute ST elevation myocardial infarction. A code STEMI was called XXX time and the cath lab was activated. I spoke with DR. XXX of cardiology who agreed to take this patient directly to cardiac catheterization. Defibrillator pads were placed on the patient. The patient was given Aspirin and Plavix. After a chest x-ray was performed which showed no mediastinal widening IV heparin was given based on the patients weight. The patient had normal hemodynamics during the ED course and was taken directly to the cardiac cath lab.
Emergency Medicine
Cardiology

Syncope Negative Statement
No evidence of a cardiac arrhythmia such as Brugada, WPW, HOCM, Long or short QT. Neurologic exam is nonfocal, not consistent with CVA or primary neurologic abnormality.
Emergency Medicine
Cardiology

Arterial Line Placement #02
After consent was obtained, the right/left radial/brachial/axillary/femoral region was prepped and draped in the standard sterile fashion. Collateral flow was confirmed to the extremity by occlusion of the artery. The artery was then punctured with pulsatile flow confirmed and a guidewire passed into the vessel. The needle was removed and a catheter was easily inserted into the artery over the guidewire. The guidewire was then completely removed and the catheter attached to the pressure transducer in a sterile fashion. Once an adequate wavefore was confirmed, the catheter was secured in place. The patient tolerated the procedure well without complications
Emergency Medicine
Critical Care

Cardiac Arrest JG #01
During the code, possible causes of asystole were reviewed, including hypoxia (100% oxygen via XXX tube), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on phys exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology.
Emergency Medicine
Critical Care

Central Line Procedure Note #01
The risks were noted to include bleeding and pneumothorax. The indication for the procedure were XXX. A timeout was performed. Nursing staff were present and the patient was monitored using telemetry and continuous pulse oximetry. The patient was placed in the Trendelenburg position and the neck was prepped chlorhexidine and a sterile full body drape was placed. Sterile technique including gown, mask, and gloves were used and antibacterial hand gel was used before gloving. The ultrasound machine, using a sterile probe cover, was used to visualize the internal jugular vein by the compression technique. The skin was anesthetized with local infiltration with 3 cc of 1% lidocaine and an 18 gauge finder needle was used to enter the internal jugular vein. Venous blood was aspirated and a guidewire was threaded through the needle into the vein. The soft tissues were dilated and the needle was removed. An XXX was threaded over the guidewire in the standard Seldinger technique and secured at XXX cm. The guidewire was removed and all ports flushed and aspirated blood without difficulty. A sterile dressing and Biopatch were applied. A postoperative chest X-ray showed the line to be in good position in the XXX without any evidence of pneumothorax. I was present for the entire procedure and there were no complications.
Emergency Medicine
Critical Care

Central Line Procedure Note #02
Informed consent was obtained after explaining benefits, risks, and alternatives to care. The area prepped/draped in sterile fashion. The vessel was visualized under ultrasound guidance. Finder needle inserted under direct visualization with US and venous non-pulsatile blood return obtained. Guidewire inserted, finder needle removed, introducer catheter inserted and removed. Catheter inserted via Seldinger technique. Guidewire removed. Blood return from each port and flushed. Secured with sutures and covered with Tegaderm. Insertion confirmed with chest xray.
Emergency Medicine
Critical Care

Conscious Sedation #02
INDICATION: XXXX. Informed consent obtained. The patient is AAOx3 before procedural sedation. No prior problems with anesthesia or sedation. Procedural sedation performed using XXXX mg of XXXX. Adequate anesthesia and analgesia achieved. Patient on a cardiac monitor and nasal cannula during the procedure, and had no signs of respiratory distress. Pt monitored until AAOx3 again. Pt tolerated sedation with no complications.
Emergency Medicine
Critical Care

Critical Care JG #01
Given the critical condition in which the patient arrived, the patient was immediately assessed by myself and the nurse, and cardiac monitoring initiated due to the potential for rapid decompensation of the patient's clinical condition. During the course of the patients stay, I spent a considerable amount of time at the bedside performing serial re-evaluations of the patient's hemodynamic and clinical status because of the recognized potential threat to life or limb in this condition. I then had a chance to review not only all of the available current laboratory and radiographic studies obtained today, but I also reviewed old records available to me at the time. Additionally, any ancillary information available including paramedic records were reviewed. Sequential vital signs were obtained. Critical Care time of XXX minutes was performed exclusive of billable procedures
Emergency Medicine
Critical Care

Expiration Discharge #01
Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupil were fixed and dilated at 8mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at __________. Patient's family was contacted and did not desire autopsy, chaplain services were offered, and funeral arrangements were discussed.
Emergency Medicine
Critical Care

Intubation #02
Airway assessed andthe patient was adequately preoxygenated with NRB. The patient was placed in the optimal sniffing position for intubation. RSI used to pre-medicate patient. Intubated with XXX ETT to XXX cm measured at the lip, cuff inflated, stylet removed. Placement confirmed by CO2 color capnography, bilateral breath sounds, equal chest rise, and chest xray confirmation.
Emergency Medicine
Critical Care

Paracentesis #02
PROCEDURE: Diagnostic & Therapeutic Paracentesis, U/S guided. The area of the LEFT/RIGHt abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. 1% lidocaine was used to numb the region. The paracentesis catheter was inserted and advanced with negative pressure under ultrasound guidance. No blood was aspirated. Clear yellow fluid was retrieved and collected. Ascitic fluid WAS/WAS NOT collected and sent for laboratory analysis. The catheter was then connected to the vaccutainer and XXX liters of additional ascitic fluid were drained. The catheter was removed and no leaking was noted. The patient tolerated the procedure well without any complications.
Emergency Medicine
Critical Care

Ultrasound IV Placement #01
A peripheral IV catheter was placed under dynamic ultrasound guidance with dark nonpulsatile blood return. Catheter confirmed in compressible vein post insertion via ultrasound. No extravasation in surrounding site after the procedure. Will continue to monitor.
Emergency Medicine
Critical Care

Negative Rash Statement
No evidence of erythema multiforme, SJS/TEN, Lyme, cellulitis, necrotizing fasciitis, no angioedema, meningococcemia, rocky mountain spotted fever.
Emergency Medicine
Dermatology

Rash Discharge #01
Does not appear at this time to be erythema multiforme, bullous, SJS, TEN; no evidence at this time to suggest RMSF or endocarditis or Lyme disease; patient looks well, nontoxic and is tolerating oral intake; no neurologic signs or symptoms; no headache or photophobia or neck pain; no ev of sepsis; question viral exanthema; afebrile; appropriate for initial o/p tx; d/w pt importance of f/u and pt agrees/understands; told pt to return to nearest ER immediately for any worsening ssx incl but not limited to: fever, spreading rash, pain, sore throat, headache, dizziness, chest pain, trouble breathing, or any ssx concerning to the patient. I did d/w pt the aforementioned ddx as possibilities and pt understands to f/u even if better and to return to ER if un-changed/worse. Pt understands these instructions on d/c and is comfortable with discharge plan.
Emergency Medicine
Dermatology

Constipation Discharge #01
Take Colace 100-200 mg up to three times per day. You may take along with Senokot 1-2 tabs, ingest with full glass of water. Maintain fluid intake 6-8 glasses per day. Please increase fibers in your diet. You may also take Milk of Magnesia 30 mL as needed for constipation, you may repeat in 2 hours again if no bowl movement.
Emergency Medicine
Gastroenterology

Gastroentertitis Discharge #01
You should return to the hospital if you experience return of persistent nausea and vomiting that does not resolve and does not allow you to tolerate any food or fluids, persistent fevers for greater than 2-3 more days, increasing abdominal pain that persists despite medications, persistent diarrhea, dizziness, syncope (fainting), or for any other concerns. For more information about how to make your own rehydration solution if you experience diarrhea/vomiting please visit: http://rehydrate.org/solutions/homemade.htm
Emergency Medicine
Gastroenterology

Paracentesis #01
The indication for the paracentesis is XXXX. Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The ultrasound machine was used to identify the most accessible fluid pocket and the abdomen was prepped with betadine and draped in sterile fashion. Sterile technique including mask, gown, and gloves were used. The skin was anesthetized using 3 cc of 1% lidocaine and an 18 gauge introducer needle was used to aspirate peritoneal fluid and then a catheter was threaded through the needle. XXX cc of peritoneal fluid were taken from the abdomen and the catheter was removed. Peritoneal fluid ***WAS/WAS NOT*** sent for analysis. Gauze was placed where the procedure was performed. No persistent leak was appreciated. I was present for the entire procedure and there were no complications
Emergency Medicine
Gastroenterology

Against Medical Advice #01
The patient has requested to leave the ED against medical advice. The patient reason(s) for leaving include, but are not limited to, the following: XXXX. I believe this patient is of sound mind and competent to refuse medical care. The patient is responding and asking questions appropriately. The patient is oriented to person, place and time. The patient is not psychotic, delusional, suicidal, homicidal or hallucinating. The patient demonstrates a normal mental capacity to make decisions regarding their healthcare. The patient is clinically sober and does not appear to be under the influence of any illicit drugs at this time. The patient has been advised of the risks, in layman terms, of leaving AMA which include, but are not limited to death, coma, permanent disability, loss of current lifestyle, delay in diagnosis. Alternatives have been offered - the patient remains steadfast in their wish to leave. The patient has been advised that should they change their mind they are welcome to return to this hospital, or any other, at any time. The patient understands that in no way does an AMA discharge mean that I do not want them to have the best medical care available. To this end, I have provided appropriate prescriptions, referrals, and discharge instructions. The patient ***did/did not*** sign AMA paperwork. The above discussion was witnessed by another member of staff.
Emergency Medicine
General

Against Medical Advice Call Back #01
The patient had earlier left the Emergency Department against medical advice. I have called them back and discussed *** xxx *** with them OR left a message and encouraged and welcomed them to return to the Emergency Department to allow us to help them with their medical concerns.
Emergency Medicine
General

Against Medical Advice JG #04
The patient is clinically sober, AA&Ox3, free from distracting injury. Throughout our interactions in the ED today, the patient has demonstrated concrete thinking/reasoning, has maintained an orderly/reasonable conversation, appears to have intact insight/judgment/reason and therefore in our opinion has capacity to make decisions. Given the patients presentation, we communicated our concern for XXXX in laymans terms. The patient verbalized an understanding of our worries. Weve told the patient that the ED evaluation is incomplete & many troublesome conditions havent been r/o. We have discussed the need for further ED w/u so we can get more information about XXXXXX. We have discussed the range of possible dx, potential testing & treatment options. Weve made numerous efforts to prevent the pt from leaving AMA. Our discussions included the potential outcomes of leaving AMA, including worsening of their condition, becoming permanently disabled/in pain/critically ill, or death. Despite these efforts, we were unable to convince the pt to stay. The patient is refusing any further care and is leaving against medical advice. We have attempted to offer tx/rx/guidance for any dangerous conditions which are most likely and/or dangerous. We have answered all questions and have implored the patient to return ASAP to complete the w/u. A staff member witnessed the patient consenting to AMA.
Emergency Medicine
General

Fever Negative Statement
No evidence of encephalitis, bacterial meningitis, pneumonia, soft tissue infection, joint infection, meningococcemia, intraabdominal infection such as appendicitis, cholecystitis, no evidence of UTI, no risk factors or findings concerning for endocarditis, no evidence of lyme disease.
Emergency Medicine
Infectious Disease

Gonorrhea and Chlamydia Treatment #01
Will empirically treat for GC/Chlamydia with Ceftriaxone IM and Azithromycin. GC culture sent. Abstinence and safe sex precautions were provided and the patient demonstrated understanding.
Emergency Medicine
Infectious Disease

Sepsis Red Flags Negative #01
Patient denies cough, nasal congestion, abdominal pain, nausea, vomiting, recent antibiotic use, diarrhea, dysuria, urinary frequency, new rashes or injuries, headaches, neck stiffness, photophobia, and sick contacts.
Emergency Medicine
Infectious Disease

Motrin JG #01
Please take IBUPROFEN (aka MOTRIN, ADVIL) 400 mg and/or ACETAMINOPHEN (aka Tylenol) 500 mg every 6 hours, as needed, for pain. Please do not take these medications if you have a bleeding disorder, stomach or GI ulcer problems or liver disease.
Emergency Medicine
Medication

Opioid Discharge #01
Will discharge patient with a short course of opiates. Went over the risks of the medication. Advised patient to not mix with other products containing acetaminophen, to not combine with alcohol, or other illicit drugs, to not drive or operate machinery, and to refrain from any activity that will require complete attention while taking this medication.
Emergency Medicine
Medication

Percocet JG #01
Please take one tablet of PERCOCET every 6 hours, as needed for SEVERE pain. Please do not take this medication unless you absolutely need it, it is very addictive. Please do not drive, operate heavy machinery or make important decisions while on this medication, it can cloud your judgement.
Emergency Medicine
Medication

Against Medical Advice #02
I informed this patient of the need for further medical evaluation and care given the patient's current medical condition. This patient declined further medical evaluation and treatment. I informed this patient of the benefits of further medical evaluation and care at this facility. I informed this patient of the risks of leaving against our medical advice without properly completing our evaluation today that include illness, injury, permanent disability and even death. The patient was also informed about alternatives. I informed the patient of the possible necessity for hospital admission depending on future findings. At the time of discussion, this patient maintained full faculties of judgement and medical decision-making capacity. In accordance with this patient's wishes, the patient was discharged from the emergency department against our medical advice in stable condition with normal vital signs in no acute distress.
Emergency Medicine
Medicine

Against Medical Advice #03
At the time of discharge, this patient demonstrated full faculties medical capacity and judgement. In my conversation with this patient they demonstrated the following: 1. This patient demonstrated their ability to express and communicate their choice to leave the emergency department against medical advice and to refuse further medical care. 2. This patient demonstrated the ability to understand relevant information regarding their diagnosis including the purpose of recommended treatment for their stated medical condition. The patient remembered this information and demonstrated that they were part of the decision making process in the course of their care. 3. This patient appreciated the significance of their medical condition, their diagnosis, and the consequences for leaving the emergency department against medical advice and refusing further medical treatment. This patient demonstrated clear understanding of the benefits of further evaluation and treatment. This patient demonstrated clear understanding of the risks of leaving against medical advice and refusing further medical treatment that include injury, illness, permanent disability, and death. 4. This patient demonstrated the ability to manipulate information regarding their medical condition, their decision to leave the emergency department against medical advice, and their decision to refuse further medical care. The patient demonstrated appropriate reasoning and intact logical thought processes during our conversation and was able to weigh the risks and benefits of receiving further medical care.
Emergency Medicine
Medicine

Alcohol Discharge #01
Recommend cessation of alcohol use, or at the least avoid heavy alcohol consumption. Strongly recommend alcohol rehabilitation/ detox: see enclosed list of centers (you must make the calls yourself for entrance into the program). Return immediately if you develop signs of withdrawal.
Emergency Medicine
Medicine

Alcoholic #01
The patient drinks alcohol XXX times a week for XXX years. The patients last drink was XXX and amount XXX . Health education about alcohol drinking and hazards were given and we recommended to stop alcohol drinking.
Emergency Medicine
Medicine

Discharge JG #01
1) Please follow-up with your primary care doctor in the next 1-2 days. Please call tomorrow for an appointment. If you cannot follow-up with your primary care doctor please return to the ED for any urgent issues. 2) You were given a copy of the tests performed today. Please bring the results with you and review them with your primary care doctor. 3) If you have any worsening of symptoms or any other concerns please return to the ED immediately. 4) Please continue taking your home medications as directed.
Emergency Medicine
Medicine

History of Present Illness #01
Intensity / Severity, Quality / Character, Onset / Duration, Radiation, Context, Aggravating factors. Alleviating factors. Associated Signs and Symptoms
Emergency Medicine
Medicine

Review of Systems JG #01
Denies fever, chills, chest pain, SOB, palpitation, dizziness, weakness, N, V, D, abdominal pain, bladder and bowel problems, leg swelling, sick contacts, or recent travel.
Emergency Medicine
Medicine

Two Midnight Rule
At the time of this inpatient admission, I believe this patient will require at least two midnights of inpatient hospital care for the history, risk factors, comorbidities, findings, diagnoses and/or interventions listed:
Emergency Medicine
Medicine

Kidney Stone #01
Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with oral narcotics for pain control, Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
Emergency Medicine
Nephrology

Bells Palsy Discharge #01
Follow up with Neurology within 3-5 days. Please take Prednisone 60mg for 9 more days. Please take Valacyclovir 1000mg three times a day for 7 more days. Apply eye drops every 2 hours and tape your eye closed when you are asleep. Please return to the Emergency Department for any new or worsening symptoms.
Emergency Medicine
Neurology

Bells Palsy Discharge #02
You have a condition called Bells Palsy. You will be prescribed several medications to help alleviate this disease. 1)Please take the steroid PREDNISONE once a day for the next 7 day. 2)Please take the antiviral medication as directed. 3)Please use the artificial tears as directed. 4)Please tape the affected eye shut at night. This will prevent your eyes from drying out and potentinally developing a deep scratch called an ulcer.
Emergency Medicine
Neurology

Concussion Discharge #01
Based on the events which brought you to the ER today, it is possible that you may have a concussion. A concussion occurs when there is a blow to the head or body, with enough force to shake the brain and disrupt how the brain functions. You may experience symptoms such as headaches, sensitivity to light/noise, dizziness, cognitive slowing, difficulty concentrating / remembering, trouble sleeping and drowsiness. These symptoms may last anywhere from hours/days to potentially weeks/months. While these symptoms are very frustrating and perhaps debilitating, it is important that you remember that they will improve over time. Everyone has a different rate of recovery; it is difficult to predict when your symptoms will resolve. In order to allow for your brain to heal after the injury, we recommend that you see your primary physician or a physician knowledgeable in concussion management. We will give you a list of neurologists, they are the specialists for head injuries. We also advise you to let your body and brain rest: avoid physical activities (sports, gym, and exercise) and reduce cognitive demands (reading, texting, TV watching, computer use, video games, etc). School attendance, after-school activities and work may need to be modified to avoid increasing symptoms. We recommend against driving until until all symptoms have resolved. You should take 650mg of Acetaminophen (Tylenol) every 4 hours as needed for pain control; however, taking anti-inflammatory medication (Motrin/Advil/Ibuprofen) is not advised. Come back to the ER right away if you are having repeated episodes of vomiting, severe/worsening headache/dizziness or any other symptom that alarms you. We recommended that someone stay with you for the next 24 hours to monitor for these worrisome symptoms.
Emergency Medicine
Neurology

Dizzy or Syncope ROS #01
No evidence of an arrhythmia such as Brugada, WPW, HOCM, Long or short QT, significant AV dissociation, or significant bradycardia. Neurologic exam is nonfocal, not c/w CVA or primary neurologic abnormality.
Emergency Medicine
Neurology

Headache Medical Decision Making #01
The patient presents with an acute onset headache for {Hours/Days} in duration. Patient has no past history of headaches. There {Is/Is Not} a history of anticoagulation, trauma, pregnancy, cancer or immunocompromised state. Mental status was normal, no neurological deficits were noted. Differential Diagnosis considered includes hypertensive emergency, subarachnoid hemorrhage, meningitis, trauma, CVA, migraine. IV was placed and {Meds} given with {Outcome} relief of symptoms. CT head was negative for acute bleed, infarct, mass, or shift. LP was performed and was negative for WBC or xanthochromia/consistent with *** The patient improved significantly and was discharged in stable condition. Recommendations were given for follow-up with PCP in 1-2 days and to return to the ED for worsening of headache or any other concerns
Emergency Medicine
Neurology

Headache Medical Decision Making JG #01
Based on the patient's history and physical there is very low clinical suspicion for significant intracranial pathology. The headache was NOT sudden onset, NOT maximal at onset, there are NO neurologic findings, the patient does NOT have a fever, the patient does NOT have any jaw claudication, the patient does NOT endorse a clotting disorder, patient DENIES any trauma or eye pain and the headache is NOT associated with dizziness or ataxia. Will treatment the patient symptomatically and reassess.
Emergency Medicine
Neurology

Head Trauma Discharge #01
Follow up with your primary care doctor within 48-72 hours. Rest. Take Acetaminophen (Tylenol) every 4-6 hours, as needed, for pain. Often individuals develop a headache associated with nausea in the days/hours after a head injury. This is called a concussion and does not warrant a return to the ED UNLESS: you develop significant worsening of pain, profuse vomiting, dizziness, changes in vision, difficulty walking/speaking, weakness or numbness to your extremities.
Emergency Medicine
Neurology

Lumbar Puncture #03
Both verbal and written consent were obtained, patient informed of risks including pain, infection, bleeding and understands and accepts these risks. Patient placed in lateral decubitus position, draped and prepped in a sterile manner using betadine x 3, and locally anesthetized with 3 cc of 1% lidocaine. Approximating the L3/L4 interspace, a standard LP needle was placed in this location, yielding ***** fluid consistent with CSF. Patient tolerated the procedure well, there were no complications.
Emergency Medicine
Neurology

Negative Headache Statement
No evidence of subarachnoid hemorrhage, intracranial bleed, meningitis, encephalitis, temporal arteritis, or intracranial mass.
Emergency Medicine
Neurology

Neuro Red Flags #01
Patient denies new weakness on one side of the body, diplopia, vertigo, slurred speech, headache, or difficulty walking.
Emergency Medicine
Neurology

Seizure Discharge #01
Please follow up with Neurology in the next 1-2 days as an outpatient. Please continue taking your medications as prescribed. Do not drive or swim until cleared to do so by your neurologist. Return for worsening condition or any other emergencies.
Emergency Medicine
Neurology

Nurse ED Discharge #01
The patient was discharged from ED. IV lock removed. No erythema/infiltrate noted. The patient verbalized understanding of discharge instructions.
Emergency Medicine
Nursing

Diclegis #01
Please take 10 mg of Pyridoxine and 10mg of Doxylamine at bedtime. If that does not work increase to 20mg of each medicine on a daily basis at bedtime; if symptoms not adequately controlled, increase dose to 40mg tablets each day (10mg of each pill in AM, 10mg of each pill in the mid-afternoon, and 20mg of each pill at bedtime).
Emergency Medicine
Ob / Gyn

Pregnancy RhoGAM #01
Due to the patients abdominal pain and pregnancy status an ultrasound was performed to assess fetal location which showed XXX. Because the patient was having some vaginal bleeding as well their RH status was determined to be XXX and RhoGAM was / was not given.
Emergency Medicine
Ob / Gyn

Vaginal bleed Discharge #01
You should return to the hospital if you continue to have persistent and heavy vaginal bleeding, persistent pelvic pain not relieved by your prescribed medications, dizziness, shortness of breath, new and persistent fevers, other foul smelling discolored vaginal discharge, or for any other concerns. For more information about recommendations for heavy menstruation please visit the American College of Obstetrics and Gynecology Website at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women
Emergency Medicine
Ob / Gyn

Vaginal Bleed First Trimester #01
XX year old GXPX female presents with first trimester vaginal bleeding. Possible etiologies of the vaginal of bleeding were considered, including but not limited to: ectopic pregnancy, spontanous miscarriage, gestational trophoblastic disease, implantaton bleeding, molar pregnancy and fiborids. Clinically the patient looks well, no indications for transfusion and no signs or symptoms of peritonitis. An ultrasound was performed which showed XXX. Because the patient was having vaginal bleeding their RH status was determined to be XXX and RhoGAM {was / was} not given. Additional labs demonstrated: After careful consideration I believe the patient is safe to be discharged home with outpatient OB/GYN followup. I had an extensive disucssion with the patient about the possible etiologies of the vaginal bleeding and answered all their questions. I also provided education on prenatal care. The patient is agreeable to outpatient Ob/Gyn for a 48 hour BETA-HCG. I encouraged them to call if they have any questions and return to the ED for any worsening of symptoms.
Emergency Medicine
Ob / Gyn

Vaginal Bleed Medical Decision Making JG #01
Differential Diagnosis Considered: Adenomyosis, Cervicitis, Dysfunctional uterine bleeding, Ectopic pregnancy, Endometrial cancer, Hydatidiform mole, Implantation bleeding, IUD/contraceptives, Miscarriage, Placental abruption, Placenta previa, Polycystic ovarian syndrome, Postcoital bleeding, Postpartum hemorrhage, Retained products of conception, Uterine fibroids, Uterine polyp, Uterine rupture In evaluating this patient's complaint, multiple diagnoses were considered, including those listed above. Based on history, physical, clinical context, and any tests done today it is my judgment that the diagnosis/diagnoses considered do not apply to this patient and that the remaining diagnoses about either do not apply to this patient, or do not require additional emergent evaluation and treatment
Emergency Medicine
Ob / Gyn

Ankle Sprain #01
Rest, Ice and Elevation. Please take Motrin 600mg every 8 hours, as needed, for pain. Please follow up with Sports Medicine or your Primary Care Doctor in 48-72 hours for further evaluation - please call for an appointment. Please return to ED for increased pain, weakness, fever, redness, and/or tingling/numbness
Emergency Medicine
Orthopedic Surgery

Ankle Xray Read JG #01
No evidence of fracture or dislocation on prelim read of xray by ME
Emergency Medicine
Orthopedic Surgery

Arthrocentesis #01
Arthrocentesis of the LEFT/RIGHT JOINT was performed. The patients identity, procedure, and site were identified and confirmed to be correct. The appropriate equipment and staff were confirmed for the procedure. There was no evidence of overlying infection, osteochondral fracture, uncontrolled bleeding disorder, or joint prosthesis which would contraindicate arthrocentesis. The risks and benefits of this diagnostic procedure were discussed and verbal consent was obtained from the patient. The patient is AAOx3, has decisional making capacity. The skin over the joint was sterilized and then numbed with a local anesthetic. A needle was inserted into the joint w/ aspiration of XXX cc's of fluid. The fluid was sent to the lab for appropriate studies. Blood loss was minimal. A dressing was placed over the procedure site. The patient tolerated the procedure without any adverse events.
Emergency Medicine
Orthopedic Surgery

Back Pain Discharge #01
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Ambulate as tolerated and no heavy lifting. Take Motrin 600 mg every 8 hours for pain with food, Valium 5mg every 8 hours as needed for muscle spasm- do not drive or make any important decisions while on this medication for it can make you drowsy. If you experience any worsening pain, swelling, numbness, weakness please return to ER
Emergency Medicine
Orthopedic Surgery

Back Pain MDM #01
The patient presents with acute onset of back pain after XXX. Clinically this patient can be ruled out for serious pathology given there is a completely normal neurological exam, no history of IV drug use, and no history of bowel or bladder incontinence, no perianal numbness/tingling, no constipation or urinary retention. Once the patients pain was adequately controlled, the patient was able to ambulate and be discharged in stable condition with anticipatory guidance provided.
Emergency Medicine
Orthopedic Surgery

Back Pain Negative Statement
No risk factors or findings concerning for epidural abscess, diskitis, vertebral osteomyelitis, cord compression, cauda equina, vertebral fracture or bone malignancy, AAA, or pyelonephritis. Patient instructed to consider further imaging and workup through their primary care physician as an outpatient if symptoms persist.
Emergency Medicine
Orthopedic Surgery

Back Pain Red Flags #01
The patient endorse NO: fevers, chills, recent spinal procedures, bowel/bladder incontinence, IV drug use, cancer, > 50 yo, recent weight loss, trauma ,weakness numbness, tingling, dysuria, hematuria
Emergency Medicine
Orthopedic Surgery

Back Pain Red Flags #02
Patient denies fevers, IV drug use, recent back surgeries or procedures, urinary incontinence, and bowel incontinence.
Emergency Medicine
Orthopedic Surgery

Cast Care #01
Please keep your cast clean and dry, keep extremity elevated, and do not stick anything into the cast. Please use a garbage bag while showering to prevent water from entering the cast. If pain significantly worsens call or return to the Emergency Department.
Emergency Medicine
Orthopedic Surgery

Conscious Sedation #02
Indication: ***********. Pre-sedation history and examination revealed: ASA physical status 1E********; fasting duration ****** hours; family history ******(negative) for adverse anesthetic/sedative reactions; airway class ******; normal dentition/neck mobility; and no contraindications to sedation. Risks, benefits and alternatives were discussed with *************, who desired to proceed. End tidal CO2, O2 saturation, and BP constantly monitored duringsedation. A qualified nurse and additional provider were present during the sedation. The patient received ***drug/route/dose**** , achieving an appropriate level of sedation. The patient then underwent ***reduction******. Total sedation time for which I was present was ****minutes***** until minimal consciousness and responsiveness achieved, and deep/moderate sedation was no longer present. There were no significant O2 desaturations or complications during this sedation and procedure. Patient was subsequently monitored until reevaluation revealed patient was back to neurologic baseline.
Emergency Medicine
Orthopedic Surgery

Finger Reduction #01
FINGER REDUCTION PROCEDURE NOTE: Finger reduction. Indication: dislocation of [left/right] [1st-5th] finger at the [DIP/MIP/PIP] joint. Consent: The risks and benefits of the procedure including incomplete reduction, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified Procedure: Anesthesia/pain control, using aseptic technique, was administered using a digital block of [ ] ml of 1% lidocaine. The patient's distal [left/right] [1st-5th] finger was grasped and longitudinal traction applied with slight exaggeration of the deformity. The joint was gently manipulated into its normal position. A finger splint was applied. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Fracture Discharge #01
Please rest, ice and elevate the affected extremity. Please take Motrin 600mg every 8 hours, as needed, for pain (take with food). Follow up with Orthopedic Surgery in 1-2 days for further evaluation - please call for any appointment. Keep splint/cast clean, dry and on. Please use garbage bag while showering to keep splint/cast dry. Use sling/crutches. Please return to ED immediately for increased pain, tingling/numbness, swelling, redness, and fever
Emergency Medicine
Orthopedic Surgery

Fracture Reduction #01
FRACTURE REDUCTION PROCEDURE NOTE: Fracture reduction Indication: Acute fracture with displacement, requiring fracture reduction. Consent: The risks and benefits of the procedure including incomplete reduction, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified Procedure: Neurovascular exam intact prior to fracture reduction. Skin exam : No bleeding or lacerations at the fracture site. Anesthesia/pain control, using aseptic technique, was administered using a hematoma block of [ ] ml of 1% lidocaine. Reduction of the [left/right] [fracture site] was accomplished via axial traction and careful manipulation. Following adequate reduction and alignment of the fractured bone, the fracture was immobilized with a plaster splint. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Hip fracture #01
The patient is status post mechanical fall c/o {Right/Left} hip pain and inability to walk. The patient denies head trauma or LOC. No other bone injuries noted by the patient. {RIGHT / LEFT} lower extremity is short and externally rotated. Skin: over {RIGHT / LEFT} hip is clean, dry and intact; Motor: EHL/FHL/GS/TA intact; Sensory: Grossly intact Pulse: 2+dp/pt
Emergency Medicine
Orthopedic Surgery

Joint Reduction #01
JOINT REDUCTION PROCEDURE NOTE: Joint reduction Indication: Dislocation of [left/right] [joint]. Consent: The risks and benefits of the procedure including incomplete reduction, secondary fracture, nerve damage and bleeding were explained and the patient verbalized their understanding and wished to proceed with the procedure. Written consent was obtained following the discussion. Universal Protocol: a timeout was performed and the correct patient and site were verified. Procedure: Neurovascular exam intact prior to joint reduction. Skin exam: no bleeding or lacerations at the fracture site. Conscious sedation performed by emergency department attending physician. Anesthesia/pain control, using aseptic technique, was administered using a hematoma block of [ ] ml of 1% lidocaine. Reduction of the [left/right] [joint] was accomplished via [ ]. The joint was immobilized with sling / splint. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well. Post reduction films obtained and demonstrated an adequate reduction. Complications: None
Emergency Medicine
Orthopedic Surgery

Joint Reduction #01
Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. Nursing staff were present and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Once the patient was adequately sedated, the *** RIGHT/LEFT JOINT*** was reduced using the traction-counter traction technique. A postoperative X-ray revealed the joint to be adequately reduced. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. I was present for the entire procedure and there were no complications.
Emergency Medicine
Orthopedic Surgery

Orthopedic Injury Discharge #01
Rest, ice, elevate area. Apply ice to the area for 10 minutes every 2 hours for the first 2 days after the injury to reduce swelling. If you have any worsening of symptoms, including severe pain/swelling/redness/numbness/changes in sensation/weakness/paralysis or any other concerns please return to the Emergency Department immediately. Please follow up with your doctor(s) within the next 3 days, but seek medical care sooner if your symptoms persist or worsen. Please call as soon as possible for an appointment. If you cannot follow up with your doctor please return to the Emergency Department for any urgent issues. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist.
Emergency Medicine
Orthopedic Surgery

Splint #02
SPLINTING PROCEDURE NOTE: Splinting Indication: [fracture/dislocation/pain] The [area to splint] was appropriately positioned. A plaster splint was applied. Distally, the extremity was neurovascularly intact following the procedure. The patient tolerated the procedure well.
Emergency Medicine
Orthopedic Surgery

Valium Discharge #01
Take Valium 5mg every 8hrs as needed for muscle spasm. This medicaiton can cause drowsiness. Do not drive or operate heavy machinery or make important decisions while on this medication.
Emergency Medicine
Orthopedic Surgery

Child Physical Exam #01
General: Well appearing, interactive with examiner, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, oropharynx clear, no lesions, TM clear bilateral; Neck: Supple, no meningismus, no CLAD; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended, no palpable mass; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Extremities symmetric, nontender.; Skin: No rash, normal skin tone, no eccymosis, purpura or petechiae.; Neuro: Alert and Oriented appriorate for age; No focal deficit, CN 2-12 symmetric and intact.
Emergency Medicine
Pediatrics

Child Protective Services
There is NO concern for any abuse/neglect or other child protective services-related issues at this time (parents appear to be appropriately engaged, concerned, and acting in the best interests of and for welfare of the patient), although the need for such concern has been thoughtfully considered.
Emergency Medicine
Pediatrics

Croup Discharge #01
Your pediatrician can reassess the need for additional Decadron (steroids) to help reduce inflammation and swelling. If your child's respiratory distress worsens or if your child has inspiratory stridor at rest which is not improved with repositioning, please call your pediatrician or return to Emergency Department.
Emergency Medicine
Pediatrics

Fever Negative Statement #02
No e/o encephalitis, bacterial meningitis, pneumonia, soft tissue infection, joint infection, meningococcemia, intraabdominal infection (appendicitis, biliary infection, intraabdominal abscess) , no risk factors or findings concerning for endocarditis, lyme disease, RMSF, or clinical symptoms/UA suggestive of UTI.
Emergency Medicine
Pediatrics

Infant Physical Exam #01
General: Well appearing, interactive with examiner, nontoxic, no acute distress; Head: Normocephalic Atraumatic, Fontanelle not sunken or bulging; Eyes: PERRL, EOMI; ENT: Airway patent; TM clear bilateral; Oral and nasal within normal limits, no lesions; Neck: No meningismus, supple; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended, no palpable mass; no guarding, rebound, or tenderness to percussion; Musculoskeletal: extremities symmetric, nontender; Skin: No rash, no eccymosis, petechiae, or purpura, Cap refill less than 2 seconds; normal skin tone; Neuro: Alert and Oriented appropriate for age; No focal deficit, CN 2-12 symmetric and intact, no pathologic reflexes; Genitourinary/Rectal: External genitalia unremarkable, no lesions
Emergency Medicine
Pediatrics

Laceration Repair #01
Area prepped and draped in sterile fashion. Anesthestized with lidocaine. Irrigated with copious irrigation and explored for foreign body. Sutured with XXX sutures with adequate approximation of wound edges. The wound was then covered with bacitracin and sterile guaze. Instructions given to return in XXX days for suture removal in the ED or with their primary care doctor.
Emergency Medicine
Pediatrics

Nursemaid Elbow Reduction #01
Firm supination of the forearm supporting the elbow in 90 of flexion. Felt and heard audible 'click' as full supination is achieved.
Emergency Medicine
Pediatrics

Pediatric ED return precautions #01
Please return to the emergency room for: persistent fevers, persistent vomiting, inability to tolerate liquids, decreased urination, change in mental status or any other concerns.
Emergency Medicine
Pediatrics

Pediatric Pneumonia Discharge #01
Routine Home Care as follows: Please continue to take your antibiotic as prescribe - ______, _____ mg every _____ hours, for a total of ____ more days. Make sure your child drinks plenty of fluid. Please continue to make sure your child is urinating every 6 hours. Please follow up with your Pediatrician in the next 1-2 days. If your child has any concerning symptoms such as: decreased eating and drinking, decreased urinating, increased fussiness, or ongoing fever please call your Pediatrician immediately. Please call 911 or return to the nearest emergency room immediately if your child has signs of respiratory distress or trouble breathing such as: Breathing faster than normal; Your child looks like he is working hard to breathe; Tugging between the ribs when breathing; Your childs nostrils flare (move in and out) with each breath; The lips turn pale, blue or dusky grey Increased cough or congestion.
Emergency Medicine
Pediatrics

PERCARN #01
Discussed with patients family that the area and type of injury do not warrant a CT scan of the head at this time. Explained the risks and benefits. PECARN Criteria reviewed. The patient will be closely monitored in the Emergency Department for any significant changes. The family agrees with the clinical plan.
Emergency Medicine
Pediatrics

Abdominal Exam Reassessment #01
The patient appears comfortable and states that pain is improved. Tolerating oral intake. Vital signs reviewed and are normal. On repeat physical exam, the abdomen is soft and nontender All diagnostics tests reviewed and discussed with the patient.
Emergency Medicine
Physical Exam

Motor Vehicle Accident Physical Exam #01
HEENT: Atraumatic. No battle's sign or raccoon eyes. MUSCULOSKELETAL: Spine--no deformity or step off, nontender along the cervical, thoracic, and lumbar spine. SKIN: No seatbelt sign NEUROLOGICAL: Alert and oriented, no focal deficits. Sensation and strength intact throughout. Gait normal.
Emergency Medicine
Physical Exam

Physical Exam #03
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, no stridor; Neck: supple, no meningismus; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Calves symmetric, nontender, no palpable cord; Skin: No rash, normal skin tone; Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact
Emergency Medicine
Physical Exam

Physical Exam #04 JG
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent, no stridor; patent oropharynx w/o erythema or exudate, uvula midline Neck: supple, no meningismus; trachea midline; Chest: Lungs clear to auscultation bilateral; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding, rebound, or tenderness to percussion; Musculoskeletal: Calves symmetric, nontender, no palpable cord; Skin: No rash, normal skin tone; no clubbing, no cyanosis, no edema Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact; memory intact, no apraxia, no agnosia.
Emergency Medicine
Physical Exam

Triage Physical Exam #01
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI; ENT: Airway patent; Neck: supple; Chest: Equal chest rise, non labored breathing; Skin: No visible rash, normal skin tone; Neuro: Alert and Oriented to person, place, and time; No focal deficit
Emergency Medicine
Physical Exam

Adult Protective Services
There is NO concern for any abuse/neglect or other adult protective services-related issues at this time (family members and/or collateral historians appear to be appropriately engaged, concerned, and acting in the best interests of and for the welfare of patient), although the need for such concern has been thoughtfully considered.
Emergency Medicine
Psychiatry

Alcohol Discharge JG #02
1) Please do not drink alcohol or ingest any mind-altering substances and drive or make important decisions. Please cut down on your substance use/abuse. 2) You were given information about substance use/abuse. Please review this literature. 3) If you have any worsening of symptoms please return to the ED immediately. 4) Please follow-up with your primary care doctor in the next 5-7 days for evaluation of symptoms.
Emergency Medicine
Psychiatry

Alcohol Reassessment JG #01
Patient seen and reassessed. Patient is AAOX3, NAD, able to ambulate, non-tremulous, and tolerating oral intake. VSS. Patient states that they feel safe going home and have a safe way to get home. Give copy of tests performed. Discussed need to cut down on substance intake, given literature.
Emergency Medicine
Psychiatry

Fit for Confinement
There are no acute medical issues requiring hospitalization. The patient does not appear to have an acute medical condition at the time of discharge that would preclude confinement. The patient should return for repeat evaluation should any new or worsening symptoms develop.
Emergency Medicine
Psychiatry

Intoxication Discharge #01
The patient is clinically sober. The patient is alert and oriented x 3, is clear and coherent in conversation and has a normal gait and shows no signs of acute intoxication. The patient is safe for discharge.
Emergency Medicine
Psychiatry

Medical Clearance for Psychiatry #01
Medical evaluation performed. There is no clinical evidence of intoxication or any acute medical problem requiring immediate intervention. Final disposition will be determined by psychiatrist.
Emergency Medicine
Psychiatry

Psychiatric ED HPI #01
{AGE}, {Domicile (in/with)}, {Employed (as) / on disability (for), {marital status}, {Ethnicity/nationality/culture}, {Gender}, {Caregiver status and location}, {Main psychiatric diagnosis},{psychiatric hospitalization # + most recent}, {Prior Suicide attempts}, {prior violence}, {prior arrests}, {Active substance use}, {Prior withdrawal/DTs}, {relevant PMH} {brought in by/referred by} presenting with / seeking, in the setting of
Emergency Medicine
Psychiatry

Psychiatric Medical Clearance #01
Exam benign. No e/o trauma, toxic ingestion, electrolyte abnormality, infection, or primary neurologic abnormality. Medically stable from emergency department perspective.
Emergency Medicine
Psychiatry

Psychiatry discharge #01
At present, protective factors outweigh the risk factors. The patient does not appear to be at imminent danger to self/ others at present, denies suicidal thoughts and will be referred to outpatient psychiatrist/ therapist.
Emergency Medicine
Psychiatry

Smoking Cessation #01
Due to patients current smoking history I had an extensive discussion lasting more than 3 minutes about the need to quit smoking. I consoled the patient of the various negative side effects of smoking including, but not limited to, the risk of developing COPD, Lung cancer, and other cardiac diseases. I strongly recommended that patient stops smoking and the patient was given various options of smoking cessation tools such as NRT's and other pharmacotherapies.
Emergency Medicine
Psychiatry

Asthma Discharge #02
You should return to the hospital if: you begin to develop worsening shortness of breath/difficulty breathing despite treatment with your prescribed medications, if you develop fevers for greater than 2 days, worsening cough, or for any other concerns with your breathing or any other problems. For more information on Asthma please visit the American College of Chest Physician's Website at: http://www.chestnet.org/Foundation/Patient-Education-Resources/Asthma
Emergency Medicine
Pulmonology

Asthma Discharge #04
Please follow up with your primary care doctor within 2 days. Please fill the prescription for prednisone and take as directed. Please use the albuterol inhaler, 2 puffs every 4-6 hours as needed for 2 days and then as needed after that. Remember, technique is important: shake the inhaler, insert into spacer, breath out fully, then pump the inhaler and take several slow deep breaths through the spacer aerochamber with your mouth. Always use the spacer aerochamber whenever you use the inhaler. Please take all of your other medications as previously prescribed. If you have any worsening wheezing, shortness of breath, chest pain, fever, chills return to the ED.
Emergency Medicine
Pulmonology

Asthma Discharge #05
Home Instructions: Take medicines as directed by your caregiver. Visit your PMD if: You have wheezing, shortness of breath, or a cough even if taking medicine to prevent attacks. You have thickening of sputum. Your sputum changes from clear or white to yellow, green, gray, or bloody. You have any problems that may be related to the medicines you are taking (such as a rash, itching, swelling, or trouble breathing). You are using a reliever medicine more than 23 times per week. Visit the ER if: You are short of breath even at rest or when doing very little physical activity. You develop difficulty eating, drinking, or talking due to asthma symptoms. You have chest pain or you feel that your heart is beating fast. You are lightheaded, dizzy, faint or have bluish lips or fingernails. You have a fever or persistent symptoms for more than 23 days or symptoms suddenly get worse. You seem to be getting worse and are unresponsive to treatment during an asthma attack.
Emergency Medicine
Pulmonology

Asthma Reassessment JG #01
Patient seen and reassessed. Discussed results w/ patient. Wheezing improved. Vital signs improved. Patient able to speak in full sentences. Repeat PEEK flow is XXX. Discussed the use of controller medications. Will dc home w/ PMD followup and strict return precautions.
Emergency Medicine
Pulmonology

Chest Tube #01
The indication for the chest tube was clinically XXX. After explaining the benefits and risks of the procedure consent (Verbal and/or Written) was obtained from the patient. The RIGHT/LEFT chest was prepped with betadine and draped in sterile fashion. Sterile technique including gown, mask, and gloves were used. The local anesthetic agent XXX was used to anesthetize the skin and pleural surface using a small caliber needle. A 1 cm incision was made using a scalpel over the 4th/5th rib in the anterior axillary line. The soft tissues were dissected using curved hemostats. The pleural cavity was pierced using a blunt curved clamp and the pleural cavity was entered. An XXX French chest tube was placed through the hole and slid posteriorly and cephalad. The chest tube was secured at XXX cm with silk suture. The chest tube was attached to a Pleura-vac container. A sterile occlusive dressing was applied. A postoperative chest x-ray showed the chest tube to be in good position. I was present for the entire procedure and there were no complications.
Emergency Medicine
Pulmonology

PERC #02
No history of DVT/PE/cancer, calf pain/swelling, hemoptysis, OCPs, or recent trauma/surgery/immobilization.
Emergency Medicine
Pulmonology

Pneumonia Discharge #01
Pneumonia is a lung infection that can cause a fever, cough, and trouble breathing. Please continue all antibiotics as directed until complete. Nutrition is important - eat small frequent meals. Get lots of rest and drink fluids. Call your Primary Care Doctor upon arrival home from the hospital and make a follow-up appointment in XXX days. If your cough worsens, you develop a fever greater than XXX, you develop shaking chills, a fast heartbeat, trouble breathing and/or feel you are are breathing much faster than usual, call your Primary Care Doctor or return to the ED. Make sure you wash your hands frequently.
Emergency Medicine
Pulmonology

Pulmonary Fibrosis Discharge #01
Pulmonary fibrosis is scarring of the lung air sacs that send oxygen to the blood which causes shortness of breath. Exact cause not known but happens more with active or former smokers, those with exposure to toxic chemicals or pollution, family history, & breathing certain types of dust at work over a long time. You can help the progression of the disease by quitting smoking, getting flu and pneumonia vaccines, using supplemental oxygen as necessary. Please take medications as directed.
Emergency Medicine
Pulmonology

Pulmonary Hypertension Discharge #01
Take all medicines as told by your caregiver. If you have problems with a prescribed medicine, talk to your caregiver. Do not stop taking it on your own. Do not smoke. Eat a healthy diet. Avoid a high salt diet. Talk to a dietician (food specialist) about foods you should eat. Stay as active as possible. Avoid high altitudes. Be careful when using a hot tub. A hot tub can lower your blood pressure. If you have pulmonary hypertension and are female of childbearing age, talk to your caregiver about using birth control pills or getting pregnant. SEEK IMMEDIATE MEDICAL CARE IF: You have severe shortness of breath. You develop chest pain or pressure. You cough up blood. You develop swelling of your feet or legs. You have a sudden increase in weight.
Emergency Medicine
Pulmonology

Smoking Cessation #01
Quitting smoking is the single most important thing you can do to improve your health. In the strongest terms, I recommend that you quit as soon as possible. You can contact your doctor for more help.
Emergency Medicine
Pulmonology

Chest X-ray Interpretation #01
Interpreted by ED Physician: CXR (1 view): no acute abnormality: no infiltrates, bones appear intact, cardiac silhouette within normal limits.
Emergency Medicine
Radiology

Chest Xray Interpretation #01
Interpreted by MD: _ x-ray, _ views Lungs clear, heart shadow normal, bony structures normal, no free air under diaphragm, no pneumothorax.
Emergency Medicine
Radiology

Abdominal Pain ROS #01
No evidence of pancreatitis, AAA, cholecystitis, choledocholithiasis, cholangitis, mesenteric ischemia, small bowel obstruction, diverticulitis, colitis, appendicitis, or pelvic etiology such as ovarian torsion, TOA, or ectopic pregnancy.
Emergency Medicine
Surgery

Chest Tube #02
Both verbal and written consent were obtained, patient informed of risks including pain, infection, bleeding, placement in the wrong location, respiratory failure and understands and accepts these risks. Patient placed in the supine position. The lateral chest wall was draped and prepped in a sterile manner using chlorhexidine and betadine and locally anesthetized using 10 mL of 1% lidocaine with epi. The space between the mid axillary line and the anterior axillary line, and above the 5th rib were targeted. Using sterile technique an incision was made at and parallel to the 5th rib, soft tissue was dissected using kelly clamp and tunneled through the intercostal muscles directly over the superior aspect of the rib, and using gentle pressure, the pleural cavity was entered. Cavity confirmed with palpation of digit, no liver palpated, no adhesions. A size **** chest tube was then inserted into the pleural cavity to a length of *****. Immediate chest tube output noted to be *****. Placement confirmed with condensation coinciding with the patients respiration. Secured to skin with 2-0 nylon, vaseline gauze, and taped to patient, and connected to drainage system. Patient tolerated procedure well, no complications. Placement confirmed by Xray.
Emergency Medicine
Surgery

Incision and Drainage of Abscess #02
XX year old with fluctuant erythematous indurated mass - likely an abscess. Lido anesthetic, betadeine prep, I+D, pack, Clinda, wound follow up.
Emergency Medicine
Surgery

Small Bowel Obstruction #01
XXX year old Male / Female with XXX days of diffuse abdominal pain presents to the emergency department. The patient has (+)/(-) nausea, (+)/(-) emesis for XXX hours (+)/(-) constipation since XXX. (+)/(-) hematochezia (+)/(-) fevers (+)/(-) chills (+)/(-) melena (+)/(-) diarrhea. CT scan confirms a small bowel obstruction with a transition point at XXX. An NGT was placed after which XXX ml of bilious fluid was suctioned from the GI tract.
Emergency Medicine
Surgery

Fall Negative Statement #01
_ yo MF presents transferred from _ s/p fall _ hours ago from _ feet, neg LOC GCS _ hemodynamically stable. Head CT negative for fracture, negative for intracranial bleed. Cervical spine CT negative for for fracture or dislocation. Chest CT/Xray negative for fracture, pneumothorax. Abdominal CT negative for intrabdominal bleeding, solid, or holo viscous injury. Plevic Xray negative for fracture. The patient is not on aspirin, plavix, Coumadin, or any other blood thinners.
Emergency Medicine
Trauma

FAST JG #01
A coronal plane of the right upper quadrant was obtained and was negative for anechoic fluid in the right chest, in Morrison's pouch, or the right paracolic gutter. suprapubic window was negative for free fluid posterior and lateral to the bladder. Next, a coronal plane of the left upper quadrant was obtained and was negative for anechoic fluid in the left chest, the splenorenal space, and the left paracolic gutter. ext, subcostal and parasternal long windows of the heart were negative for the presence of free fluid in the pericardial space. These images were captured on the internal hard drive for archival and quality assurance purposes.
Emergency Medicine
Trauma

Negative Trauma Statement
No evidence of skull fracture, intracranial bleed, dental trauma, cervical, thoracic, or vertebral fracture or subluxation, no suspicion of thoracic, abdominal, pelvic or extremity injury by exam.
Emergency Medicine
Trauma

Trauma Physical Exam #01
General: Well appearing, nontoxic, no acute distress; Head: Normocephalic Atraumatic; Eyes: PERRL, EOMI, No e/o ocular trauma; ENT: Airway patent, Oral and nasal within normal limits, no e/o septal hematoma, no e/o dental trauma; Neck: No midline cervical tenderness or deformity, no anterior mass or crepitus, trachea midline; Chest: Lungs clear to auscultation bilateral, no chest wall tenderness or crepitus; Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops; Abdomen: soft, nontender, nondistended; no guarding or rebound; Musculoskeletal: Extremities symmetric, nontender, and without deformity proximal and distal, no pain with axial loading; Skin: No rash, normal skin tone; no seatbelt sign at neck, chest, or abdomen; Neuro: Alert and Oriented to person, place, and time; No focal deficit, CN 2-12 symmetric and intact; Back: No thoracic or lumbar midline tenderness or deformity
Emergency Medicine
Trauma

Trauma ROS #02
No e/o skull fracture, intracranial bleed, dental trauma, cervical, thoracic, or vertebral fracture or subluxation, no e/o of thoracic, abdominal, or pelvic injury.
Emergency Medicine
Trauma

Trauma ROS JG #01
On physical exam no battle sign appreciated, no nasal-septal hematoma, no clear leakage from ears, nose or eyes suggestive of CSF leakage. There is no bony stepoffs or deformities. The patient moves all extremities without difficulty.
Emergency Medicine
Trauma

Kidney Stone Discharge #01
Follow up with your primary doctor within 2-3 days. Follow up with a Urologist this week (we will give you a list of urologists, but make sure they accept your insurance). Please call as soon as possible for an appointment. We have sent a prescription for Flomax (0.4mg daily) to your pharmacy. Please pick up the medication as soon as possible and take as directed. Use Motrin (also called Ibuprofen or Advil) 400 mg every 6 hours as needed for pain. If you have any stomach discomfort while taking Motrin, you can use TUMS to help. All of these medications can be purchased without a prescription. Drink plenty of fluids, avoid caffeine & alcohol. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist. Any worsening pain, fever, chills, difficulty urinating, or any other concerns, please see your doctor immediately or return to Emergency Department right away.
Emergency Medicine
Urology

Kidney Stone Discharge JG #02
Please take 1 tablet of PERCOCET every 6 hours, as needed for SEVERE pain. Please do not drive or operate heavy machinery while on this medication because it can impair your judgement. This is a very addictive medication, do not take it unless you absolutely have to. Please take 400 mg of MOTRIN (also know as Advil or Ibuprofen) every 6 hours, as needed for MILD pain. Do not that this medication if you have any history of ulcers or kidney disease. Please take FLOMAX once a day at bed. This medication may make you sleepy. Please follow-up with UROLOGY in the next 2-3 days - you were give a referral list. Please bring your labs and imaging with you to your appointment.
Emergency Medicine
Urology

UTI Discharge #01
UTI Discharge: HOME CARE INSTRUCTIONS - you were prescribed antibiotics, take them exactly as your caregiver instructs you. Finish the medication even if you feel better! Drink enough water and fluids to keep your urine clear or pale yellow. Avoid caffeine, tea, and carbonated beverages - these can irritate your bladder. Empty your bladder often. Avoid holding urine for long periods of time. Empty your bladder before and after sexual intercourse. After a bowel movement, women should cleanse from front to back. Use each tissue only once. SEEK MEDICAL CARE IF: You have back pain. You develop a fever. Your symptoms do not begin to resolve within 3 days. SEEK IMMEDIATE MEDICAL CARE IF: You have severe back pain or lower abdominal pain. You develop chills. You have nausea or vomiting. You have continued burning or discomfort with urination.
Emergency Medicine
Urology

Abscess Discharge #01
You have had an abscess drained in the Emergency Department and you may have had packing placed in the wound to help the abscess continue to drain at home. Please do not remove the packing. You may shower with the packing in place - let the soapy water clean your wound, do not scrub at it. Keep your wound covered to prevent transmission of infection to other people. Follow up with your primary care physician or in the Emergency Department in XXX days for a wound check and/or packing removal. Return to the Emergency Department immediately if you develop any of the following symptoms: Fevers, Increased redness or swelling around where your abscess was, Increased pain, or Generalized weakness or vomiting
Emergency Medicine
Wound Care

Abscess Discharge #02
Please return to ED or your Primary Care Doctor in 2 days for a wound check and packing change. Keep the wound covered and dry as directed. Return to ED for any increased pain, redness, or fever.
Emergency Medicine
Wound Care

Abscess Discharge #03
Please return to ED or see your doctor in 2 days for wound recheck and/or packing change. Please Keep the wound covered and dry. Once a day: wash the wound with soap/water, apply bacitracin or neosporin and re-cover the wound. If you have any worsening of symptoms, including severe pain/swelling/numbness/changes in sensation/weakness, redness which expands more than it is right now or any other concerns please return to the ED immediately.
Emergency Medicine
Wound Care

Dermabond #01
The patient had a laceration that was XXX cm in length. The wound was irrigated and cleaned. No foreign bodies were appreciated. It was subsequently closed with Dermabond in 4 layers.
Emergency Medicine
Wound Care

Incision and Drainage of Abscess #01
Verbal consent were obtained. The indication for the procedure was clinical suspicion for an abscess. **Yes/No confirmation with an ultrasound was performed.** The region was anesthetized with **local anesthetic**. The most fluctuant portion of the abscess was incised with an **xx** blade scalpel. The abscess cavity of explored and evacuated, all loculations were broken up with a curved hemostat. The cavity was then packed with packing material and dressed with a clean gauze dressing. I was present for this entire procedure and there were no complications.
Emergency Medicine
Wound Care

Laceration Discharge #01
Follow up with your primary care doctor within 48-72 hours for a wound check. Keep sutures covered and dry for 24 hours then clean with soap and water daily - do not scrub. Apply bacitracin and cover with gauze. Return to ED for suture removal 7 days. Return to the ED for any increased pain, redness, streaking (red lines), swelling, fever or chills.
Emergency Medicine
Wound Care

Laceration Discharge JG #02
Keep the wound clean and as dry as possible. Do not immerse or soak the wound in water. This means no swimming, washing dishes (unless thick rubber gloves are used), baths, or hot tubs until the stitches are removed or after about two weeks if absorbable suture material was used. Leave original bandages on the wound for the first 24 hours. After this time, showering or rinsing is recommended, rather than bathing. the first day, remove old bandages and gently cleanse the wound with soap and water. Cleansing twice a day prevents buildup of debris and will result in easier suture removal.
Emergency Medicine
Wound Care

Laceration Repair #02
Verbal consent was obtained, and patient was provided with risks and alternatives to the procedure. Wound was copiously irrigated with ******tap/NS******, cleansed with chlorhexidine, and anesthetized with *****XXX mL of lidocaine****. Wound carefully explored and no foreign body, tendon injury, or nonviable tissue were noted. Using sterile technique ******XXX-0 suture/staples**** was used to reapproximate the wound. ****XXX interrupted-sutures were placed. Patient tolerated procedure well, no complications. Patient advised to look for and return for any signs of infection such as redness, swelling, discharge, or worsening pain. Patient advised to return for suture removal within ******7-10 days****.
Emergency Medicine
Wound Care

Splint #01
The patients {EXTREMITY} was splinted with XXX inches of Orthoglass. The patient was neurovascularly intact after the procedure. The patient tolerated the procedure well, all questions addressed and answered.
Emergency Medicine
Wound Care

Suture #01
The laceration was identified to be XXX cm in length and located at XXX. The laceration was cleansed with XXX and all debris was removed. Local anesthesia was obtained by injecting XXX at the laceration site. The laceration was then irrigated with XXX cc of high-pressure irrigation. The wound was explored and no foreign bodies were found. There were no tendon or nerve lacerations. The wound was closed with *** XXX suture type, number, and technique***. A sterile dressing was then applied and anticipatory guidance was provided.
Emergency Medicine
Wound Care

Suture Removal #01
Verbal consent was obtained. Wound well approximated, no erythema, induration, or discharge noted. *****XXX sutures***** completely removed in a sterile fashion. Patient tolerated procedure well, no complications. Patient advised to look for and return for any signs of infection such as redness, swelling, discharge, or worsening pain.
Emergency Medicine
Wound Care

Suture removal JG #01
AFTER the stiches are removed: Clean your wound as directed. Carefully wash your wound with soap and water. Pat the area dry with a clean towel. Protect your wound. Your wound can swell, bleed, or split open if it is stretched or bumped. You may need to wear a bandage that supports your wound until it is completely healed. Minimize your scar. Use sunblock if your wound is exposed to the sun. Apply it every day after the stitches are removed. This will help prevent skin discoloration.
Emergency Medicine
Wound Care

Wound Discharge #01
Wound dressed with topical Bacitracin and sterile gauze. Instructed to return tomorrow morning for a wound check- leave dressing until then. Afterwards apply Bacitracin OTC BID and do warm soaks BID. Strict instructions to return for worsening redness, swelling or pus.
Emergency Medicine
Wound Care

Abdominal Pain Discharge #01
Please return to the emergency department immediately should you feel worse in any way or have any of the following symptoms: increasing or different abdominal pain, persistent vomiting, fevers or shaking chills. Please return to the emergency department for a recheck in 8-12 hours if the pain is persistent or worse so we can re-evaluate you and ensure that you are not developing a problem that would require surgery or hospitalization.
Emergency Medicine

Abdominal Pain Discharge #02
On repeat examination prior to discharge, the patient has a soft abdomen with no peritoneal findings. The patient was able to tolerate oral intake. The patient was advised that even though there is no evidence of a surgical emergency at this time, sometimes this is not visible on ***IMAGING*** or in the labs early in a disease course and that if there is additional pain they are to return for repeat evaluation. The patient stated understanding of this, has decisional making capacity and is discharged in stable condition. The patient was instructed to return to the emergency department for re-evaluation in 8-12 hours and sooner if they feel worse in any way.
Emergency Medicine

Alcohol Intoxication
Patient demonstrates clinical evidence for alcohol intoxication. The patient admits to intentional heavy drinking of alcohol and denies fall or injury. The patient also denies drug use. Some of the history and physical exam is limited due to the state of intoxication. All clothes were removed, all parts of the body were evaluated and there is no evidence of acute trauma. The plan is to observe patient in the ED until clinical sobriety is reached and reassess history and physical examination.
Emergency Medicine

Allergic Reaction Discharge #01
Please follow-up with your primary doctor(s) within 2-3 days. Please avoid any known triggers of your allergies. We recommend you see an Allergist - we have given you a list of allergists (check with your insurance before making any appointments). You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. We have sent a prescription for an Epi-Pen to your pharmacy. Please pick it up as soon as possible. Always carry this with you. In the Emergency Department today, we spoke about how to use the Epi-Pen only in the event of a severe allergic reaction with trouble breathing or throat swelling. You must go to the hospital right away if you ever use the Epi-Pen. Remember that they expire every year so you should have your doctor write a new prescription yearly. We have sent a prescription for prednisone to your pharmacy. Please pick it up as soon as possible and use as directed (40mg once daily for 4 more days). Take Benadryl (also called diphenhydramine) 25mg every 6-8 hours as needed for further allergy symptoms (can be purchased without a prescription) - please note that Benadryl often causes drowsiness so please do not drive, make important decisions or operate machinery until you know how it will affect you. Please return to the Emergency Department right away if you have any worsening or new shortness of breath, changes in your voice, tightness/itching in your mouth/throat, swelling, severe hives, chest pain, high fever. There is a very small chance of a recurrence of the allergic reaction, typically in the next 24 hours. If you see the same symptoms (rash, trouble breathing, vomiting, etc) return, come back to the Emergency Department immediately.
Emergency Medicine

Ankle Injury Discharge #01
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Recommend orthopedic follow up within the week; a referral list was provided. Please keep the affected extremity elevated, rest it and please keep compression wrap on. Take Motrin 600 mg every 8 hours for pain, as needed, with food. Ambulate as tolerated using crutch assistance. If you experience any worsening pain, swelling, numbness, weakness please return to ER
Emergency Medicine

Antibiotic DC #02
Please fill the prescription for the antibiotics and take as directed. Please finish the entire course of medication as prescribed. Do not use any alcohol or grapefruit juice with any antibiotics.
Emergency Medicine

Cellulitis Discharge #02
Please follow up with your Primary Care Doctor within 48-72 hours - call for an appointment. Rest and elevate affected area. Take Motrin 600mg every 8 hours with food for pain. Please take Antibiotics as directed. If you experience any worsening redness, swelling, streaking (red lines), fever or chills please return to ED
Emergency Medicine

Conscious Sedation #01
Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The indication for sedation were: XXX. The patient had been NPO for greater than 4 hours. Time out was completed. Respiratory therapy and nursing staff were present at bedside and the patient was monitored using continuous pulse oximetry and telemetry. The patient was pre-oxygenated using high flow oxygen. IV MEDICATION was used to achieve sedation and the procedure was performed. Subsequently, the patient was monitored until the sedation wore off and the patient was alert and recovered. The total time for the procedure was XXX minutes and I was present for the entire procedure and there were/were not complications.
Emergency Medicine

Constipation Discharge #01
Please follow up with your primary care doctor within 2-3 days, bring your results with you. For constipation we also recommend a diet high in fiber (beans, fruits, vegetables, whole grains). If the diet does not work then please take Docusate (also called colace) 100mg 1-2 times a day as needed. This medication is available over the counter. Return to the Emergency Department for any new or worsening symptoms.
Emergency Medicine

Drug Seeker #01
The patient is manifesting multiple drug seeking attributes. Prior medical records, if available, were reviewed. Discussed with the patient that opioid pain medication will not be given during the ED visit. Alternative analgesia is offered and REFUSED/ACCEPTED.
Emergency Medicine

Drunk Discharge #01
Please stop drinking to excess. Return to ED for seizures, shaking, confusion, intractable vomiting, blood in vomit or any other concerning symptoms. Please do not drink and drive.
Emergency Medicine

DVT Medical Decision Making #01
Leg swelling most worrisome for DVT, no evidence of arterial insufficiency DDx includes DVT, thrombophlebitis, edema (cardiac, renal, hepatic dz), trauma, lymphedema, baker's cyst. Will obtain lower extremity US to evaluate for DVT; we discussed with the patient that a repeat Lower Extremity US will be needed in 5-7days if US in ED is normal
Emergency Medicine

DVT Negative Discharge #01
Even though the ultrasound of your leg in the Emergency Department today did not find a clot, it is still important that you repeat the ultrasound in 5-7 days because of the very small chance that a clot was too small to see on today's ultrasound. Please follow up with your doctor(s) within the next 3 days, but seek medical care sooner if your symptoms persist or worsen. Please call as soon as possible for an appointment. If you cannot follow up with your doctor please return to the Emergency Department for any urgent issues. You were given a copy of the results from any tests performed today in the Emergency Department which have results available. Show these to your doctor(s). Some of the tests we sent may not have results yet so please call or have your doctor call the Emergency Department to follow up on all results. If you have any worsening of symptoms or any other concerns please see your doctor or return to the Emergency Department immediately. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist.
Emergency Medicine

ED Discharge #01
Discussed results and outcome of testing with the patient. The patient was advised to follow up with their primary care doctor within the next 24-48 hours and return to the Emergency Department for worsening symptoms or any other concerns. Patient given a phone number to follow up on the specific results of the tests performed today in the emergency department.
Emergency Medicine

ED Sign-out #01
The patient was signed out to the incoming physician. All decisions regarding the progression of care and interpretation of tests will be made at their discretion.
Emergency Medicine

Foreign Body #01
Wound explored for a foreign body in a sterile field. Copious irrigation was provided with no evidence of a foreign body. Discussed the potential of retained foreign body with patient and signs/symptoms that should prompt immediate return to the ED for reevaluation.
Emergency Medicine

Foreign Body #01
Wound explored for foreign body and copious irrigation provided with no evidence of FB. Discussed the potential of retained foreign body with the patient and signs/symptoms that should prompt the patient to immediately return to the ED for reevaluation.
Emergency Medicine

Head Injury Discharge #01
Follow up with your Primary Care Doctor within 48-72 hours. Rest, take Tylenol 650 mg 1 tab every 4-6 hours, as needed, for pain. If you experience any nausea, vomiting, worsening pain, dizziness or changes in vision return to ED.
Emergency Medicine

Lumbar Puncture #01
The indication for the procedure was rule out XXX. Consent (verbal and/or written) was obtained from the patient after the risks and benefits were discussed. The patient was placed in the XXX position. The lumbar portion of the back was prepped with betadine and draped in sterile fashion. Sterile technique including gown, gloves, and mask were used. The skin over the L2-L4 vertebrae was anesthetized using 3 cc of 1% lidocaine without epinephrine. A 22 gauge spinal needle was used to enter the subarachnoid space and XXX cc of CSF spinal fluid was obtained. The opening pressure was. CSF samples were sent to the lab for xanthochromia, cell count, glucose, protein, gram stain, and culture. The needle was removed and the patient was instructed to lay flat for one hour to prevent the development of a post-dural headache. I was present for the entire procedure and there were no complications.
Emergency Medicine

Lumbar Puncture #02
A lumbar puncture was performed to rule-out Intracranial bleed vs Infection. The back was prepped and draped in sterile fashion. Landmarks were identified. The area was infiltrated with 1% Lidocaine. A (22) gauge spinal needle was inserted into the interspace between L4-L5. Approximately (3) mL of (clear) CSF was obtained and sent to the lab for further analysis. The needle was withdrawn and a bandage applied. The patient was instructed to lie flat after the procedure. There were no complications and the patient tolerated the procedure well.
Emergency Medicine

Meningitis Negative #01
Kernig and Brudzinski signs are negative, no petechiae, no photophobia, no dysarthria, no facial asymmetry, and no focal deficits. Very low clinical suspicion for meningitis.
Emergency Medicine

Midlevel Note #01
I performed a face to face evaluation of this patient and obtained an independent history and exam. I agree with the above history, physical exam and plan of the midlevel provider.
Emergency Medicine

Midlevel Note #02
Per institutional requirements, I have reviewed the chart, however was not consulted specifically or made aware of this patient by the above midlevel provider and did not personally evaluate, interact with, or disposition this patient on the day of their visit.
Emergency Medicine

Motor Vehicle Accident (MVA) #01
XXX year-old patient with no significant PMHx presents to the ED for {s/p car vs. car} MVA today. Pt was {restrained/unrestrained} {driver/front seat passenger/driver's side rear passenger} when XXX; {positive/negative} airbag deployment. Was able to ambulate after the collision. Denies head injury, LOC, dizziness, numbness/tingling, or any other injuries. Able to move all extremities without difficulty.
Emergency Medicine

Needlestick Medical Decision Making #01
I have reviewed the Chief Complaint, the HPI, the ROS, and have directly performed and confirmed the findings on the Physical Examination. I have reviewed the medical decision making with all providers, as applicable. The MOST LIKELY DIAGNOSIS at this time is: occupational exposure to blood, source patient unknown status for HCV, HBV and HIV. The list of differential diagnoses includes, but is not limited to, the following: possible infectious disease transmission, including, but not limited to, HIV, HBV and HCV. The likelihood of each of these diagnoses has been appropriately considered in the context of this patient's presentation and my evaluation. PLAN: (1) post-exposure prophylaxis protocol (2) supportive wound care measures, as warranted clinically (3) anticipatory guidance (4) observation and serial evaluations (5) outpatient followup with primary care physician/provider and EHS. I will continue to reevaluate the patient, including the results of all testing, and monitor response to therapy throughout the patient's course in the ED.
Emergency Medicine

NEXUS #01
The patient was ruled out for C-spine injury via NEXUS criteria.
Emergency Medicine

NEXUS #02
Because the patient is A&Ox3, has no focal neurologic deficits, no posterior midline c-spine tenderness to palpation, no evidence of intoxication and has no painful distracting injuries there is no need to obtain radiographic studies to evaluate the cervical spine.
Emergency Medicine

PERC #01
Risk factors for pulmonary embolism by PERC criteria: Age < 50, Pulse < 100, SaO2 > 94%, No unilateral leg swelling, No hemoptysis, No recent surgery, No prior PE or DVT history, No exogenous hormone use. Based on this criteria the patient is low/high risk by PERC.
Emergency Medicine

Reassessment JG #01
The patient was seen and reassessed. Patient symptomatically improved. AAOX3, NAD, VSS. Discussed test results w/ patient, given copy of results. Patient verbalized understanding of hospital course and outpatient plans, has decisional making capacity. Will follow-up with Primary care doctor in the next 1-2 days; patient will call for an appointment. Will return to the ED if there is any worsening of symptoms. Patient able to ambulate w/o difficulty, is tolerating PO intake.
Emergency Medicine

Smoker #01
The patient is an active smoker, smokes XXX ppd for XXX years. Health education about smoking hazards was provided and recommended to stop smoking.
Emergency Medicine

Suture wound check #01
Please follow up with your primary doctor (or come back to the ED) within 48-72 hours for wound check. Please keep sutures/staples covered & dry for 2 days, then clean with soap/water, apply bacitracin and cover the wound once daily. Return to ED for suture removal in XXX days. Any increased pain, redness, streaking (red lines), swelling, fever, chills please immediately return to ER.
Emergency Medicine

Syncope EKG Negative #01
There are no signs of ischemia, WPW, ARVD, long QT, HOCM or Brugada on the Emergency Department EKG.
Emergency Medicine

Transfer #01
The patient requires hospital admission. The patient has been stabilized to the best of this emergency department's capabilities. Given the patient's medical needs and in light of the patient's preferences, appropriate facilities for transfer were discussed and the decision has been made to transfer this patient to XXX Hospital. The receiving facility has the capacity as well as the capabilities to provide care for the patient. I contacted Dr. *** who has accepted the patient in transfer. EMTALA transfer paperwork has been completed. Patient has been informed and updated of their current clinical status. The patient has given consent for the transfer - the risks and benefits were explained and the patient verbalizes understanding. . The patient will be transported by ambulance.
Emergency Medicine

Viral Illness Discharge #01
Follow up with your Primary Care Doctor within 48-72 hours for further evaluation. Please rest and drink plenty of fluids to remain hydrated. Please wash your hands regularly. Please take Acetaminophen 650 mg every 6 hours for pain or temp greater than 100. If you have any worsening or continued fever, chills, weakness, nausea, vomiting, abdominal pain return to ED
Emergency Medicine

Diabetes DC #01
Make sure you get your HgA1c checked every three months. This test monitors the severity of your diabetes. If you take oral diabetes medications, check your blood glucose two times a day. If you take insulin, check your blood glucose before meals and at bedtime. It's important not to skip any meals. Keep a log of your blood glucose results and always take it with you to your doctor appointments. Keep a list of your current medications, including injectables, and bring this medication list with you to all your doctor appointments. If you have not seen your ophthalmologist this year please call for an appointment. Check your feet daily for redness, sores, or openings. If you develop these signs/symptoms do not self-treat. Please, follow-up with a podiatrist (foot doctor) or your primary care doctor. Low blood sugar (hypoglycemia) is defined as a blood sugar below 70mg/dl. Check your blood sugar if you feel signs/symptoms of hypoglycemia. If your blood sugar is below 70 take 15 grams of carbohydrates (ex 4 oz of apple juice, 3-4 glucose tablets, or 4-6 oz of regular soda) wait 15 minutes and repeat blood sugar to make sure it comes up above 70. If your blood sugar is above 70 and you are due for a meal, have a meal. If you are not due for a meal have a snack. This snack helps keeps your blood sugar at a safe range.
Endocrinology
Medicine

Diabetes Instructions #01
The patient has been instructed on how to monitor their blood sugar and maintain a consistent carbohydrate diet. The patient is instructed to check their feet daily for open wounds or sores, get their eyes checked once a year and teeth cleaned twice a year. The patient was given a glucometer, test strips and taught how to use these devices. The patient was told to keep a blood sugar diary. The patient was instructed to exercise daily - start slowly and increase their activity as their comfort level dictates.
Endocrinology
Nutrition

Lefort Post-op #01
Instructed patient to apply ice to face 20 min on and then 20 min off. Sign above patients head. Scissors/ wire cutter at a bedside as well as Yankuer. Instructed patient no straws, no spitting, no nose blowing, no sinus pressure, sneeze with mouth open .Will keep the head of the bed elevated at 30-degree angle at all times.
ENT
Nursing

Septoplasty Post-Op #01
Please do not consume hot or spicy food. Please cough and sneeze with mouth open. Please avoid nose blowing.
ENT
Plastic Surgery

Tonsillectomy Diet #01
Cool and warm liquids that are not irritating to the throat should be given for the first day or two. Avoid hot liquids. Avoid citrus juices and milk. Advance at your own pace starting with soft foods and advancing to a regular diet. Avoid rough and scratchy foods and foods that are difficult to chew for approximately 5 days. Avoid strenuous exercise and blowing of nose.
ENT
Surgery

Tonsillectomy Post-op #01
Avoid harsh gargling or tooth brushing. This can cause bleeding. Gently rinse your mouth as directed to remove blood and mucus. Your face and neck may be swollen or tender after surgery, Wrap a bag of crushed ice in a towel and place it on your neck as directed. Use a cool humidifier in your home to help moisten the air and soothe your throat. Your throat may be sore up to 2 weeks after surgery. Some ear and throat pain happens with any throat operation. You may have small or large amounts of bleeding from the surgery areas up to 7 days. Most bleeding happens within 24 hours after surgery. Large amounts of bleeding need to be treated right away. Contact the doctor if you feel weak, dizzy, or like you might faint when you sit up or stand, have back/ chest pain, or difficulty breathing.
ENT
Surgery

Ear Surgery Post-Op #01
For the first 2 weeks - sneeze with mouth open, do NOT blow nose, and avoid strenuous physical activity. Please keep soap and water out of the ear and keep it dry. Please do not stick Q-tips into the ear canal. Notify your physician if you have significant increase in vertigo.
ENT

Ulcerative colitis Discharge #01
Ulcerative Colitis Discharge HOME CARE INSTRUCTIONS: There is no cure for ulcerative colitis disease. The best treatment is frequent checkups with your primary care doctor and gastroenterologist. . Periodic reevaluation is important. Symptoms such as diarrhea can be controlled with medications. Avoid foods that have a laxative effect such as: fresh fruit and vegetables and dairy products. During flare-ups, you can rest your bowel by staying away from solid foods. Drink clear liquids frequently during the day. Electrolyte or rehydrating fluids are best. Your caregiver can help you with suggestions. Drink often to prevent dehydration. When diarrhea has cleared, eat smaller meals and more often. Avoid food additives and stimulants such as caffeine (coffee, tea, many sodas, or chocolate). Avoid dairy products. Enzyme supplements may help if you develop intolerance to a sugar in dairy products (lactose). Ask your caregiver or dietitian about specific dietary instructions. If you had surgery, be sure you understand your care instructions thoroughly, including proper care of any surgical wounds. Take any medications exactly as prescribed. If possible, avoid stresses that aggravate your condition. Exercise regularly. Follow your diet. Always get plenty of rest. SEEK MEDICAL CARE IF: Your symptoms fail to improve after a week or two of the new treatment. You experience continued weight loss. You have ongoing crampy digestion or loose bowels. You develop a new skin rash, skin sores, or eye problems. SEEK IMMEDIATE MEDICAL CARE IF: You have worsening of your symptoms or develop new symptoms. You have an oral temperature above XXX, not controlled by medicine. You develop bloody diarrhea. You have severe abdominal pain.
Gastroenterology
Emergency Medicine

Cirrhosis DC #01
Cirrhosis is scarring of the liver. Common causes include heavy alcohol use, hepatitis B or C, or fatty liver. PREVENTION: Please avoid alcohol, speak with your doctor before starting on any new medication, herbs, vitamins, or supplements which may cause more damage to the liver. TREATMENT: Treat the underlying cause, reduce blood pressure, consume a low-salt diet, please continue taking diuretics. You may require abdominal fluid drainage (paracentesis). Please obtain regular vaccinations to prevent common infections. SEEK MEDICAL CARE IF: If you develop abdominal or leg swelling, shortness of breath, bruising or bleeding easily, feeling full/bloated, too much or too little sleep, yellowing of the skin or the whites of your eye, sudden confusion, or coma.
Gastroenterology
Hepatology

Colitis DC #01
HOME CARE INSTRUCTIONS: Get plenty of rest. Drink enough water and fluids to keep your urine clear or pale yellow. Eat a well-balanced diet. Call your primary care doctor for follow-up as recommended. SEEK IMMEDIATE MEDICAL CARE IF: You develop chills. You develop a fever. You have extreme weakness, fainting, or dehydration. You have repeated vomiting. You develop severe abdominal pain or are passing bloody or tarry stools
Gastroenterology
Medicine

Gastritis DC #01
Call your health care provider if: You develop stomach pain that progressively gets worse or doesn't go away; If you vomit blood or have black bowel movements; If you are losing weight (without trying); Avoid: NSAIDs- (e.g. Aspirin, Advil, Ibuprofen Motrin, Naproxen, Aleve)' Avoid alcoholic beverages; Take all medications as prescribed.; Call your healthcare provider for a follow-up appointment within one week
Gastroenterology
Medicine

Bereavement #01
Educated family on bereavement counseling/support group(s) such as Social Work, Pastoral Care, and/or Registered Nurses to help with their loss.
General
Social Work

Coumadin #01
Please have your PT/INR levels checked on XXXX and again on XXXX and then weekly. Please have all blood work fax to XXXX and follow up with XXXX for any adjustments needed to your Coumadin (Warfarin) dosage.
Hem / Onc
Cardiology

Sickle Cell Discharge #01
Sickle cell anemia is when red blood cells are abnormal. The RBCs get stuck together and are unable to bring enough oxygen to your organs. Call your doctor if any signs of infection, swelling, nausea or vomiting. Avoid dehydration by drinking an adequate amount of fluids. Avoid stress. Avoid high altitude places and mountains where there is less oxygen. It is important to treat infections right away even in the middle of the night - call your doctor with any temperature higher than XXX. Keep your regular check up appointments with your doctor and follow his instructions carefully Keep up with your vaccinations to prevent certain infections Take medications as prescribed - you also will be on folic acid.
Hem / Onc
Emergency Medicine

Thrombocytopenia Discharge #01
HOME CARE INSTRUCTIONS: Check the skin and linings inside your mouth for bruising or bleeding as directed by your caregiver. Check your sputum, urine, and stool for blood as directed by your caregiver. Do not return to any activities that could cause bumps or bruises until your caregiver says it is okay. Take extra care not to cut yourself when shaving or when using scissors, needles, knives, and other tools. Take extra care not to burn yourself when ironing or cooking. Ask your caregiver if it is okay for you to drink alcohol. Only take over-the-counter or prescription medicines as directed by your caregiver. Notify all your caregivers, including dentists and eye doctors, about your condition. SEEK IMMEDIATE MEDICAL CARE IF: You develop active bleeding from anywhere in your body. You develop unexplained bruising or bleeding. You have blood in your sputum, urine, or stool.
Hem / Onc
Emergency Medicine

Coumadin DC #01
This medication is used to thin the blood, to prevent and treat blood clots. Take this medication daily as prescribed by your physician. Tell your Dentist, Surgeon, and other Doctors that you are on this drug. This medication requires PT/INR Blood work monitoring, please do not skip any outpatient appointments checking these levels.
Hem / Onc
Medicine

DVT DC #01
Please take your "blood thinners" as prescribed. Walking and light exercise is encouraged - please increase activity as tolerated. If you develop new leg pain, swelling, and/or redness contact your doctor. If you develop new chest pain with difficulty breathing, a rapid heart rate and/or a feeling like 'passing out' please call emergency services immediately.
Hem / Onc
Medicine

Myelodysplastic Syndrome Discharge #01
In Myelodysplastic Syndrome (MDS) the bone marrow does not work normally - it makes abnormal blood cells. There are different types of MDS so you need a bone marrow biopsy to tell this information. Call your doctor if you feel weak, tired, dizzy, trouble thinking clearly, trouble breathing, bruising or bleeding easily, or get infections more easily. Your doctor will decide what treatment you will need to control this disease - it may include blood transfusions, medication, &/or chemotherapy. It is important to visit your doctor as directed.
Hem / Onc
Medicine

DVT Education #01
Signs and symptoms of DVT and its prevention reviewed with the patient. Ambulation encouraged.
Hem / Onc

Bacterial Infection Discharge #01
Take all antibiotics as ordered. Call your Primary Care Doctor upon arrival home to make a follow-up appointment. If you develop fever, chills, malaise, or change in the mental status call your Primary Care Doctor or go to the Emergency Department. Nutrition is important, eat small frequent meals to help ensure you get adequate calories. Do not stay in bed all day - Increase your activity daily as tolerated.
Infectious Disease
Emergency Medicine

Clostridium Difficile DC #01
If you no longer have diarrhea you do not have to do anything special. Good hand washing is always important. If you still have diarrhea, you and your family members should follow these guidelines: Wash your hands before you eat and prepare food. Wash your hands well after you use the toilet. Wash your hands well before and after you care for a person with C. Difficile. Wear disposable gloves if you must handle stool. Clean the bathroom daily with disinfectant cleaner (diluted bleach). Put disposable waste, like diapers or other such items, into plastic bags. Tie the bags securely, and throw them out with the regular trash. If clothes are heavily soiled with stool, wash them separately in detergent and bleach. Clothes not soiled with stool can be washed with other clothing.
Infectious Disease
Medicine

Pradaxa #01
The medication Pradaxa/Dabigatran is used to "thin the blood" so clots will not form and to keep existing ones from getting bigger. This medication may cause you may bleed more easily. Be careful and avoid injury. Use a soft toothbrush and an electric razor. Take this medication daily. You may take this medication with food or water to prevent an upset stomach. If you miss a dose call your health care provider or pharmacist right away. Prior to any procedures please inform your physician, dentist or surgeon.
Medication
Cardiology

Xarelto #01
The medication Xarelto/Rivaroxaban is used to "thin the blood" so clots will not form and to keep existing ones from getting bigger. This medication may cause you may bleed more easily. Be careful and avoid injury. Use a soft toothbrush and an electric razor. Take this medication daily. You may take this medication with food to prevent an upset stomach. If you miss a dose call your health care provider or pharmacist right away. Prior to any procedures please inform your physician, dentist or surgeon.
Medication
Cardiology

Antibiotics DC #01
Take your medicine with a glass of water or food as indicated by your physician. Please take the medication as directed. DO NOT STOP taking them even if you start to feel better. Do not share your medication with other people. Do not use your medicine in the future for a different infection. Ask your physician about which side effects to watch for. Try not to miss any doses. If you miss a dose, take it as soon as possible
Medication
Infectious Disease

Ambien Administration #01
Ambien was administered as per physician orders and given with good effect. The patient is resting comfortably. Respirations even, unlabored. Will continue to monitor
Medication
Nursing

Colace #01
Take the medication COLACE (docusate) 100mg three times a day to prevent/help with constipation. Painkiller medications containing opioids can cause constipation.
Medication

AICD Discharge #01
Your AICD can sense and treat certain abnormal heart beats. If your AICD gives you a shock (you will probably feel it), let your doctor know so he/she can check the device & make changes in the device as needed or change your medication. Check your device as directed on a regular basis. Talk to your doctor about driving permission. Avoid electric or magnetic equipment. If you are not able to use metal detectors at airports, ask for hand security search. Tell any doctors or nurses that you have an AICD. You cannot have an MRI. You may want to get a medical alert bracelet indicating that you have an AICD. Follow directions your doctor gave you regarding arm movement & exercises, lifting, sling use. Always carry your AICD card in your wallet and remember who the manufactor is. It is important to know what brand of AICD you have in case of emergency.
Medicine
Cardiology

Angina Discharge #01
HOME CARE INSTRUCTIONS: Only take over-the-counter and prescription medicines as directed by your caregiver. Stay active or increase your exercise as directed by your caregiver. Limit strenuous activity as directed by your caregiver. Limit heavy lifting as directed by your caregiver. Maintain a healthy weight. Learn about and eat heart-healthy foods. Do not smoke. SEEK IMMEDIATE MEDICAL CARE IF: You experience the following symptoms: Chest, neck, deep shoulder, or arm pain or discomfort that lasts more than a few minutes. Chest, neck, deep shoulder, or arm pain or discomfort that goes away and comes back, repeatedly. Heavy sweating with discomfort, without a noticeable cause. Shortness of breath or difficulty breathing. Angina that does not get better after a few minutes of rest or after taking sublingual nitroglycerin. These can all be symptoms of a heart attack, which is a medical emergency! Get medical help at once. Call 911 immediately. Do not drive yourself to the hospital and do not wait to for your symptoms to go away.
Medicine
Cardiology

Atrial Fibrillation Discharge #01
Atrial fibrillation is a very most common heart rhythm problem. The condition puts you at risk for strokes and heart attacks. It helps if you control your blood pressure, not drink more than 1-2 alcohol drinks per day, cut down on caffeine, getting treatment for over active thyroid gland, and get regular exercise. Call your doctor if you feel your heart racing or beating unusually, chest tightness or pain, lightheaded, faint, shortness of breath especially with exercise. It is important to take your heart medication as prescribed. You may be on anticoagulation which is very important to take as directed - you may need blood work to monitor drug levels.
Medicine
Cardiology

Myocardial Infarction Discharge #01
Call your doctor if you have unusual chest pain, pressure, or discomfort, shortness of breath, nausea, vomiting, burping, heartburn, tingling upper body parts, sweating, cold, clammy skin, or racing heartbeat. Call 911 if you think you are having a heart attack. Take all cardiac medications as prescribed - notify your doctor if you have any side effects. Follow cardiac diet - avoid fatty & fried foods, don't eat too much red meat, eat lots of fruits & vegetables, and dairy products should be low fat. Please lose weight if you are overweight. Become more active with walking, gardening, or any other activity that gets you to moving.
Medicine
Cardiology

Patient Review #01
All available clinical, physical, laboratory, radiographic, electrocardiographic, metabolic, and hemodynamic data were reviewed and analyzed.
Medicine
Critical Care

Diabetes Education #03
You should limit yourself to 180 grams of carbohydrates daily to help lower your hemoglobin A1C to a goal of <7.0%. You should limit excessive intake of foods that are high in simple sugars such as sodas, candies, and large amounts of sweet fruits. You should also limit excessive intake of foods that are high in complex carbohydrates such as pasta, rice, and potatoes, all of which are high in starch - a complex carbohydrate. In order to further aide in dietary changes to manage your diabetes, you should maintain a food diary for one month and record the amount of carbohydrates in each meal or snack. This should be brought to your primary care doctors office and then further discussed. For more information about dietary recommendations you can visit the website for the National Diabetes Initiative at http://www.ndei.org/ADA-nutrition-guidelines-2013.aspx.
Medicine
Endocrinology

Hyperthyroidism Discharge #01
Hyperthyroidism is when your body makes TOO MUCH thyroid hormone. Call your doctor if you feel more anxious, irritable, trouble sleeping, trembling, sweating a lot, fast heartbeat, tired, weight loss, diarrhea, abnormal periods. Your doctor will monitor thyroid blood work regularly to monitor levels. It is important to take medications prescribed. Please take your medications as directed.
Medicine
Endocrinology

Hypothyroidism Discharge #01
Hypothyroidism is when you do not make enough thyroid hormone. Common signs & symptoms of low levels of thyroid hormone include but are not limited to: tired, getting cold easily, coarse or thin hair, constipation, shortness of breath, swelling, irregular periods. Your doctor will do thyroid hormone blood tests at least once a year to monitor if your medication dose is adequate. Please take your thyroid medicine as directed by your doctor & on empty stomach
Medicine
Endocrinology

Gastrointestinal Bleed Discharge #01
There are 2 common types of Gastrointestional (GI) Bleeds: UPPER GI Bleed and LOWER GI Bleed. UPPER GI Bleed affects the esophagus, stomach, and first part of the small intestine. LOWER GI Bleed affects the colon and rectum. If you have a LOWER GI Bleed notify your Health Care Provider if you are vomiting blood, or coffee ground vomitus, and bowel movements that look like black tar. If you have a LOWER GI Bleed notify your health care provider if you develop are bright red bloody bowel movements. Take your medications as prescribed by your Gastroenterologist. If you have had an Endoscopy or Colonoscopy, follow up with your Gastroenterologist for Pathology results. Avoid NSAIDs unless your Health Care Provider tells you that it is ok (Aspirin, Ibuprofen, Advil, Motrin, Aleve). Follow up with your Gastroenterologist within 1-2 weeks of discharge.
Medicine
Gastroenterology

Gastroparesis Discharge #01
Gastroparesis happens when the stomach takes too long to empty, so it causes nausea & vomiting and feeling full too soon after eating. It is common with diabetes and smoking marijuana. Call your doctor if you have severe abdominal pain, nausea or vomiting, bloating, feeling full too soon after eating, trouble eating, or weight loss. You can help yourself by eating small frequent meals during the day, put food through blender before eating it, cut down on foods with fats like cheese & fried foods, & cut down on foods wth a lot of fiber like fruits, vegetables, & beans If you have diabetes, it is important to keep blood sugars as close to normal as possible You may need to take liquid food supplements for adequate nutrition.
Medicine
Gastroenterology

GERD Discharge #01
HOME CARE INSTRUCTIONS: Change the factors that you can control. Ask your caregiver for guidance concerning weight loss, quitting smoking, and alcohol consumption. Avoid foods and drinks that make your symptoms worse, such as: Caffeine or alcoholic drinks. Chocolate. Peppermint or mint flavorings. Garlic and onions. Spicy foods. Citrus fruits, such as oranges, lemons, or limes. Tomato-based foods such as sauce, chili, salsa, and pizza. Fried and fatty foods. Avoid lying down for the 3 hours prior to your bedtime or prior to taking a nap. Eat small, frequent meals instead of large meals. Wear loose-fitting clothing. Do not wear anything tight around your waist that causes pressure on your stomach. Raise the head of your bed 6 to 8 inches with wood blocks to help you sleep. Extra pillows will not help. Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver. Do not take aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). SEEK IMMEDIATE MEDICAL CARE IF: You have pain in your arms, neck, jaw, teeth, or back. Your pain increases or changes in intensity or duration. You develop nausea, vomiting, or sweating (diaphoresis). You develop shortness of breath, or you faint. Your vomit is green, yellow, black, or looks like coffee grounds or blood. Your stool is red, bloody, or black. These symptoms could be signs of other problems, such as heart disease, gastric bleeding, or esophageal bleeding.
Medicine
Gastroenterology

Pancreatitis Discharge #01
Pancreatitis is a condition which causes severe belly pain, irritated, or swollen Pancreas. The two main causes are gallstones or alcohol abuse. Follow a low-fat diet (e.g. fried foods, desserts, whole milk dairy products, fatty meats) and avoid Alcohol. If you are prescribed antibiotics, complete the entire course. Follow up with your Gastroenterologist within XXX days of discharge.
Medicine
Gastroenterology

Iron Deficiency Anemia Discharge #01
Both hemoglobin (Hgb) and hematocrit (HcT) values are used to define anemia. These lab values are obtained from a complete blood count (CBC) test. This is performed at a caregiver's office. Iron is an essential part of hemoglobin. Without enough hemoglobin, anemia develops and the body does not get the right amount of oxygen. Iron deficiency anemia develops after the body has had a low level of iron for a long time. This is either caused by blood loss, not taking in or absorbing enough iron, or increased demands for iron (like pregnancy or rapid growth). Foods from animal origin such as beef, chicken, and pork, are good sources of iron. Be sure to have one of these foods at each meal. Vitamin C helps your body absorb iron. Foods rich in Vitamin C include citrus, bell pepper, strawberries, spinach, and cantaloupe. In some cases, iron supplements may be needed in order to correct the iron deficiency. In the case of poor absorption, extra iron may have to be given directly into the vein through a needle (intravenously).
Medicine
Hem / Onc

MRSA Discharge #01
To prevent the spread of MRSA do the following: Wash your hands Keep wounds that are draining or have pus covered with a clean dry bandage. Bandages or tape can be thrown in the regular garbage. Avoid sharing items such as towels, washcloths, razors, clothing, or uniforms that may have had contact with the infected wound or bandage. Wash sheets, towels, and clothes that become soiled with hot water and laundry detergent. Dry clothes in a hot dryer rather than air drying. This helps to kill the bacteria.
Medicine
Infectious Disease

Hyponatremia Discharge #01
Hyponatremia is when you have LOW levels of Sodium. Home care instructions: Only take medicines as directed by your caregiver. Many medicines can make hyponatremia worse. Discuss all your medicines with your caregiver. Carefully follow any recommended diet, including any fluid restrictions. You may be asked to repeat lab tests. Follow these directions. Avoid alcohol and recreational drugs. Seek Medical Care IF: You develop worsening nausea, fatigue, headache, confusion, or weakness. Your original hyponatremia symptoms return. You have problems following the recommended diet. SEEK IMMEDIATE MEDICAL CARE IF: You have a seizure. You faint. You have ongoing diarrhea or vomiting
Medicine
Nephrology

Obesity Discharge #01
HOME CARE INSTRUCTIONS: Exercise and perform physical activity as directed by your caregiver. To increase physical activity, try the following: Use stairs instead of elevators. Park farther away from store entrances. Garden, bike, or walk instead of watching television or using the computer. Eat healthily, low-calorie foods and drinks on a regular basis. Eat more fruits and vegetables. Use low-calorie cookbooks or take healthy cooking classes. Limit fast food, sweets, and processed snack foods. Eat smaller portions. Keep a daily journal of everything you eat. There are many free websites to help you with this. It may be helpful to measure your foods so you can determine if you are eating the correct portion sizes. Avoid drinking alcohol. Drink more water and drinks without calories. Take vitamins and supplements only as recommended by your caregiver. Weight-loss support groups, Registered Dieticians, counselors, and stress reduction education can also be very helpful. SEEK IMMEDIATE MEDICAL CARE IF: You have chest pain or tightness. You have trouble breathing or feel short of breath. You have weakness or leg numbness. You feel confused or have trouble talking. You have sudden changes in your vision.
Medicine
Nutrition

Lung Cancer Discharge #01
HOME CARE INSTRUCTIONS: If you smoke, stop! Take all medications as directed. Please keep all appointments with your caregiver and other specialists. Ask your caregiver if you should see a cancer specialist if that has not been arranged. If you require oxygen or breathing equipment, be sure you know how to use it and who to call with questions. Follow any special diet directions. If you have problems with appetite, ask your caregiver for help. SEEK MEDICAL CARE IF: You have had a surgical procedure are you are having trouble recovering. You have ongoing weight loss. You have decreased strength or energy past the point when your caregiver said you would feel better. You develop nausea or lightheadedness. You have pain that is not improving. SEEK IMMEDIATE MEDICAL CARE IF: You cough up clotted blood or bright red blood. Your pain is uncontrolled
Medicine
Pulmonology

Pleural Effusion Discharge #01
HOME CARE INSTRUCTIONS: Take any medicines exactly as prescribed. Please follow up with your Primary Care Doctor and/or Pulmonologist as directed. Monitor your exercise capacity (the amount of walking you can do before you get short of breath). Do not smoke - ask your Primary Care Doctor and/or Pulmonologist for help quitting. SEEK MEDICAL CARE IF: Your exercise capacity seems to get worse or does not improve with time. You do not recover from your illness. SEEK IMMEDIATE MEDICAL CARE IF: Shortness of breath or chest pain develops or gets worse. You have an oral temperature above XXX, not controlled by medicine. You develop a new cough, especially if the mucus (phlegm) is discolored.
Medicine
Pulmonology

Pulmonary Embolism Discharge #01
Take your anticoagulation as directed. Please follow up with your Primary Care Doctor within one week. Call for appointment. If you develop shortness of breath or if your shortness of breath worsens call your Primary Care Doctor or go to the Emergency Department.
Medicine
Pulmonology

SIADH Discharge #01
HOME CARE INSTRUCTIONS: Take medications as directed by your caregiver. Many medications can make hyponatremia worse. Be sure you tell your caregiver about all your medications. Carefully follow any recommended diet, including any fluid restriction. You may be asked to repeat lab tests. Be sure to follow these directions. Your caregiver may talk to you about the treatment of any underlying condition that caused the SIADH. SEEK MEDICAL CARE IF: You develop worsening nausea, fatigue, headache, confusion or weakness. You get your original hyponatremia symptoms again. You have problems following the diet recommended. SEEK IMMEDIATE MEDICAL CARE IF: You have shaking that you cannot control (seizure). You lose consciousness (black out). You have ongoing diarrhea or vomiting.
Nephrology
Emergency Medicine

Chronic Kidney Disease #01
Avoid taking: NSAIDs - (ex: Ibuprofen, Advil, Celebrex, Naprosyn) or nephrotoxic agents (e.g. intravenous contrast used in CT scans) these can damage the kidney. Please have your medications reviewed by your primary care doctor and have your medications renally adjusted. Blood pressure control is important.
Nephrology
Medicine

CT Dye #01
This patient was found to have an elevated creatinine and may be at risk for contrast induced nephropathy. Discussed risks/benefits with patient, agrees w/ scan. The patient will receive IV hydration prior to the CT scan and immediately after. Will continue to monitor.
Nephrology
Radiology

Coordination Exam #01
Coordination: Finger to nose dysmetria was not present. Heel-shin dysmetria was not present. Gait: normal Tandem gait, heel - toe walk
Neurology
Physical Exam

Cranial Nerve Exam #01
Cranial Nerves: Visual acuity intact bilaterally, visual fields full to confrontation, pupils equal round and reactive to light, extraocular motion intact, facial sensation intact symmetrically in V1-V3 bilaterally, face symmetrical, hearing was intact bilaterally, head turning and shoulder shrug symmetric and there was no tongue deviation with protrusion.
Neurology
Physical Exam

Mental Status Exam #01
Mental Status: AAOX4, fluent, attends b/l, memory intact, no apraxia, no agnosia.
Neurology
Physical Exam

Motor Exam #01
Motor: 5/5 strength in all extremities, normal tone, and bulk. Deep tendon reflexes: Biceps right 2+. Biceps left 2+ Patella right 2+. Patella left 2+.
Neurology
Physical Exam

Neuro Exam #01
Kernig and Brudzinski signs are negative, no petechiae, no photophobia, no dysarthria, no facial asymmetry, no focal deficits.
Neurology
Physical Exam

Sensation Exam #01
Sensory: intact to LT/PP/Vibr/Pos/Temp 4x.
Neurology
Physical Exam

Intracranial Hemorrhage Admit #01
[] Strict BP control goal <140/90 w/ Cardene drip; [] Repeat CTH in 24hrs or prn for worsening mental status or neuro exam; [] q2 neuro checks, vitals; [] hold aspirin, lovenox; [] TTE; [] Telemetry Monitoring; [] SCD's for DVT prophylaxis; [] MRI brain w/ and w/o cont.; [] HgA1c, Lipid profile
Neurology

Stroke Discharge #01
The patient was admitted to the {neurology floor, stroke service}. An extensive work up done including: MRI brain showing XXX and MRA of head and neck demonstrated XXX. Telemetry and TTE also showed XXX. Etiology of stroke XXX. Goal BP 140/90. Pt started on Aspirin 81 mg and Lipitor 80 mg daily. The patient was also seen and evaluated by PT/OT recommending XXX. The patient was seen by a speech and swallow recommending a XXX diet. The patient was also seen by speech language and pathology recommending XXX
Neurology

Spinal Precautions #01
The patient was educated on their spinal precautions including no lifting greater than 8lbs, no twisting, and no bending. Patient verbalized understanding of these precautions. Patient maintained spinal precautions (no lifting greater than 8lbs, no twisting, and no bending) throughout session.
Neurosurgery
Physical Therapy

Arterial Line DC #01
Arterial line discontinued as per MD order. Pressure applied for 5 minutes, no bleeding or hematoma noted after removal. Pressure dressing applied. Neurovascularly intact at this time. Will reassess in 15 minutes.
Nursing
Critical Care

Central Line DC #01
Central line discontinued as per MD order. The patient tolerated the procedure well. Pressure held at the site by staff for 30 min. No signs of bleeding or hematoma noted; pressure dressing applied.
Nursing
Critical Care

Chest Tube Monitoring #01
The patients chest tube in place and draining to wall suction. Dressing changed, dry and intact. Petroleum gauze at the bedside. Incentive spirometer given to the patient. The patient is instructed on the use of spirometer and is able to demonstrate proper use. The patient is encouraged to continue use ten times per hour. Continuous pulse ox monitoring in place. The patient encouraged to ambulate three times or more per day.
Nursing
Critical Care

Discharge Instructions #01
A safe plan for discharge was discussed with the patient and family. The patient and family were agreeable to the plan of discharge and close outpatient follow-up was arranged. A copy of the test results performed while in the hospital were provided.
Nursing
General

IV Lock #01
IV Lock in place, flushed q2 hours, no signs of infiltration
Nursing
General

Nursing Receive #01
Pt received from outside unit and verbal sign-out obtained. In no apparent distress. Patient oriented to new surroundings, placed on monitor and vitals obtained. Will continue to monitor
Nursing
General

Nursing Sign-out #01
A verbal report given to receiving RN XXXX. The patient AAOx3, VSS and aware of bed assignment. Awaiting transport.
Nursing
General

Nursing Sign-out #02
Pt assigned a bed to outside unit. A verbal report was endorsed to floor RN. Pt stable for transport; patient and/or family made aware of transfer. The chart was placed in with the charge RN.
Nursing
General

Overnight #01
Vital signs stable throughout the night, medication regimen continued. Patient slept comfortably throughout the night. Frequent rounding was provided and safety was maintained. Will continue to monitor.
Nursing
General

Patient admission education #01
The patient will verbalize understanding of their individual plan of care and safety measures. The patient will be able to verbalize the importance of calling for assistance if necessary before attempting to get-out-of-bed to help in preventing falls and/or injury. Call bell within reach.
Nursing
General

Reassess #01
No changes from previous assessment. Will continue to monitor
Nursing
General

Transfusion #01
(Product) given. Risks and benefits of transfusion explained to the patient. Patient verbalized understanding of risks and benefits, has decisional making capacity. Patient aware of possible side effects. Consent placed in the chart. Vital signs stable. Second provider at bedside witnessed consent.
Nursing
Hem / Onc

Transfusion #02
1 unit PRODUCT transfusing. Pt verbalized understanding of signs and/or symptoms of an adverse reaction and need to report these immediately.
Nursing
Hem / Onc

Transfusion #03
Prior to transfusion the patients h/h was XXX. The patient received units of blood irradiated/filtered. Blood # and exp date #. The patient was premedicated with Tylenol and Benadryl. The patient tolerated well, no reaction noted.
Nursing
Hem / Onc

Subcutaneous Heparin Education #01
The patient was educated on subcutaneous heparin administration and how it is used to prevent the formation of blood clots. The patient verbalized understanding.
Nursing
Medication

Sepsis #01
The patient meets sepsis criteria. Two large bore IV's were placed. Fluids running. Two sets of blood cultures and a VBG were sent to the lab. See EMR for antibiotics given. Will continue to monitor closely.
Nursing
Medicine

Hemodialysis SP #01
The patient is not in any distress s/p hemodialysis. Vital signs stable.
Nursing
Nephrology

Pain #01
Evaluate pain using identified tools/self-report descriptions, physiologic and behavioral indicators. Establish with the patient what level of discomfort is acceptable that will allow for maximal function. Reassess pain at regular intervals using patient-appropriate scale and terminology
Nursing
Neurology

Diet #01
The patient tolerates the provided diet well without signs of choking or aspiration.
Nursing
Nutrition

Tube Feed #01
The patient tolerates tube feeds without signs of difficulty or aspiration
Nursing
Nutrition

Constant Observation #01
Upon arrival, the patient was placed on constant observation for XXXX at XXXX time. The patient was undressed, searched for potentially harmful devices and valuables were secured. The patient will be maintained in a safe environment and de-escalation techniques will be employed if patient becomes agitated. Will continue to monitor
Nursing
Psychiatry

Mittens Placed #01
Bilateral untied mittens in place to prevent pulling of lines. Alternative measures such as: increased safety checks done prior and during applying of untied mittens. Education provided to patient and family on the reason for untied mittens. Safety and comfort checks completed every 30 minutes. Assessment for release, skin and neurovascular checks completed every 2 hours and remain within defined limits.
Nursing
Psychiatry

NG Tube #01
NGT site intact, skin assessed and intact, no redness or skin breakdown, tube offloaded.
Nursing
Surgery

NPO #01
We explained to the patient not to eat or drink anything before the procedure (NPO). Explained the risks of any intake of food or liquids. Patient demonstrates understanding.
Nursing
Surgery

Toradol #01
You were given Toradol for pain management. Please DO Not take Motrin/Ibuprofen (NSAIDS) for the next 6 hours (Until _______)
Nursing
Toxicology

Tylenol #01
You were given 1000mg IV Tylenol for pain management. Please DO NOT take Tylenol for the next 6 hours.
Nursing
Toxicology

Foley #01
A Foley catheter was inserted using sterile technique, draining by gravity, and secured with StatLock. A second provider was present to confirm sterility.
Nursing
Urology

Foley DC #01
The patient is able to spontaneously void after Foley removal. Soft, non-distended bladder appreciated
Nursing
Urology

Straight Cath #01
Straight catheterization was performed under sterile technique to obtain urine specimen from the patient. Two providers were present for the procedure. Pt tolerated the procedure well. Sterile specimen collected. UA and Culture sent.
Nursing
Urology

Incontinence #01
Patient monitored for incontinence. After each episode of incontinence the skin was cleaned with a skin cleanser, a skin barrier was applied, and one breathable underpad was placed.
Nursing
Wound Care

Skin #01
Skin integrity maintained. The patient is repositioned q2 hours and as needed.
Nursing
Wound Care

Bathing #01
The patient was bathed and skin care was provided. Oral care provided.
Nursing

Compression Stocking Education #01
The patient was educated on how sequential compression stocking are used to increase venous return for blood clot formation. The patient verbalized understanding.
Nursing

Discharge instructions #01
The patient was given detailed instructions about activity and other precautions. Diet, weight loss, and therapeutic lifestyle changes discussed with the patient. Smoking cessation also discussed with patient, if applicable.
Nursing

Lab sent #01
Labs were drawn & sent; results reviewed. MD made aware of any gross abnormalities.
Nursing

Nursing Discharge #01
The patients peripheral IV was removed, no evidence of infiltration noted at discharge. Skin intact, VSS. The patient is not complaining of pain, discomfort, or distress at this time. The patient is discharged as per MD orders in stable condition. The patient was educated and provided with printed medication list & discharge instructions. The patient verbalized and indicated understanding. Safety maintained, awaiting escort off unit.
Nursing

PACU Discharge #01
The patient meets all criteria for discharge from PACU. The patient is awake/alert/VSS. The patient is medicated for discomfort. No vomiting. No bleeding appreciated. Skin pink warm dry and intact. IV intact, site benign. Afebrile. A verbal report was given to receiving RN. The patient is aware of transition to next unit.
Nursing

Shift Change - Nursing #01
The patient report endorsed to oncoming shift RN. No signs or symptoms of distress with the patient. MD are aware of patient assessment throughout the shift. All medications were given this shift with no adverse reaction noted. No issues at this time. Will continue to monitor.
Nursing

Cardiac Diet #01
Choose lean meats and poultry without skin and prepare them without added saturated and trans fat. Eat fish at least twice a week. Recent research shows that eating oily fish containing omega-3 fatty acids (for example, salmon, trout and herring) may help lower your risk of death from coronary artery disease. Select fat-free, 1 percent fat and low-fat dairy products. Cut back on foods containing partially hydrogenated vegetable oils to reduce trans fat in your diet. To lower cholesterol, reduce saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day, thats about 13 grams of saturated fat. Cut back on beverages and foods with added sugars. Choose and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,400 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further. If you drink alcohol, drink in moderation. That means one drink per day if youre a woman and two drinks per day if youre a man. Follow the American Heart Association recommendations when you eat out, and keep an eye on your portion sizes.
Nutrition
Cardiology

Heart Diet Education #01
Provided in-depth nutrition education on a Heart Healthy diet and reviewed written education handout (limiting saturated fats and cholesterol, avoiding salt, choosing whole grains ).
Nutrition
Cardiology

Warfarin Education #01
Discussed interaction between Vitamin K and Coumadin (Warfarin), the need to keep Vitamin K intake consistent and need to closely monitor their dietary intake. Educational material provided.
Nutrition
Cardiology

Diabetes Education #01
1) Assessed patients understanding about the link between diet and diabetes. 2) Discussed consistent carbohydrate intake, consuming protein rich foods with meals and snacks and limiting concentrated sweets and salts. 3) Reinforced importance of self-monitoring blood glucose levels.
Nutrition
Endocrinology

Diabetes Education #02
With the diagnosis of diabetes comes a strict diet regimen to help control blood sugars. This diet begins with watching carbohydrate consumption. Carbohydrates such as starches, fruits, dairy and starchy vegetables are the food groups that affect glucose levels in the body most profoundly. Carefully monitoring carbohydrate intake is the main component of the diabetic diet; eating three meals each day that are roughly equivalent in size can help control blood sugars. Regular exercise and weight control can help you manage your blood sugars as well. A registered dietitian can help you plan a diet customized to your individual needs.
Nutrition
Endocrinology

Diabetic Diet #02
A registered dietician can help you create a personalized plan for healthy eating. Make your calories count by choosing: 1. Healthy carbohydrates such as fruits, vegetables, whole grains, legumes (beans, peas and lentils) and low-fat dairy products. 2. Fiber-rich foods such as vegetables, fruits, nuts, legumes, whole-wheat flour and wheat bran. 3. Heart-healthy fish at least twice a week such as cod, tuna and halibut, which are low-fat options as well as salmon, mackerel, tuna, sardines and bluefish, which are rich in omega-3 fatty acids. Avoid fish with high levels of mercury. 4. "Good" fats such as avocados, almonds, pecans, walnuts, olives and canola, olive and peanut oils. Minimize foods with high saturated fats (beef, hot dogs, sausage and bacon), trans fats (processed snacks, baked goods, shortening and stick margarines), high cholesterol foods (high fat dairy products and animal proteins, fried food) and high sodium foods (fast food, many frozen foods, processed food).
Nutrition
Endocrinology

Steroid Education #01
Discussed side effects of steroids on blood glucose and recommended avoiding concentrated sweets and limiting salt intake while taking steroids
Nutrition
Endocrinology

RD Progress #01
-Monitor weight, lab values, po intake and GI tolerance; -RD to remain available for further nutrition interventions as indicated.
Nutrition
General

Kidney Education #01
Provided nutrition education for kidney health. Discussed limiting foods high in sodium, phosphorous, potassium, and monitoring protein intake. Patient verbalized understanding.
Nutrition
Nephrology

TPN #01
TPN infusing at ml/hr (gm amino acids, gm dextrose, ml 20%lipids) to provide kcal (kcal/kg, gm prot/kg per adm wt).
Nutrition
Nutrition

Postpartum Diabetes #01
The patient was educated on postpartum dietary recommendations, including the risk of development of Type 2 Diabetes Mellitus. We reinforced importance of Diabetes Mellitus screening 6-8 weeks postpartum.
Nutrition
Ob / Gyn

OB Epidural #01
Epidural site checked: no drainage, erythema or tenderness
Ob / Gyn
Anesthesia

OB Pain #01
Patients pain effectively managed with pain medications.
Ob / Gyn
Neurology

Breastfeeding #01
The infant latched onto the breast and demonstrated good suck and swallow.
Ob / Gyn
Nursing

Breastfeeding #02
The mother demonstrated the ability to breastfeed optimally. The mother demonstrated optimal positioning, recognition of rooting, proper tongue placement, sucking and swallowing.
Ob / Gyn
Nursing

Hyperbilirubinemia #01
Infant under phototherapy. Genitals covered with a diaper, eyes covered with an eyemask. Encourage q3hour feeds. Bilirubin levels checked as per MD order. Color, cry, activity, and elimination assessed and recorded.
Ob / Gyn
Nursing

Neonatal Bilirubin #01
Baby was noted to have a high cord bilirubin, so bilirubin was trended throughout the baby's stay and noted to be below phototherapy threshold. Discharge bilirubin was ____ at ____ hours of life, ____ zone.
Ob / Gyn
Nursing

Newborn #03
Infant feeding well, voiding and passing stool. Vital signs within normal limits. Safety checks of infant and mother done per policy and maintained.
Ob / Gyn
Nursing

Newborn #04
Infant vital signs stable on room air and is maintaining appropriate thermoregulation in the isolette. Tolerating all feedings with no residuals. Infant voiding and stooling appropriately. Will continue to monitor.
Ob / Gyn
Nursing

Postpartum Reassessment #01
VSS, tolerating food, ambulating and voiding without difficulty, pain well controlled with medications, breastfeeding and bonding well with newborn, peripheral IV in place and patent. will continue to monitor
Ob / Gyn
Nursing

Postpartum Reassessment #02
The patient's pain is being effectively managed with pain control medications. The patient is feeding her infant well and demonstrates an ability to care for infant and self.
Ob / Gyn
Nursing

Prepartum Reassessment #01
Vital signs stable, fetal movements present as per patient. Patient denies cramping, vaginal bleeding or leakage of fluids. The patient is resting comfortably. Will continue to monitor
Ob / Gyn
Nursing

Newborn #01
Active, alert, tolerating feedings, stooling and voiding. VSS. Newborn is bonding well with mother.
Ob / Gyn
Pediatrics

Newborn #02
Newborn out of transition period. VS within desired limits. Pink active and alert. Voiding and feeding
Ob / Gyn
Pediatrics

Pediatric Circumcision #01
Please apply bacitracin to penis tip with each diaper change or four times a day. Some bleeding is expected. If you notice an excessive amount of bleeding or the infant seems to be excessive pain please contact your physician.
Ob / Gyn
Pediatrics

C-section #01
Infant delivered by cesarean section at XXX weeks, The patient and infant were received from L&D accompanied by L&D nurse via bassinette. Infant placed under radiant warmer servo controlled, baby on blood glucose monitoring for SGA. The mother plans to breastfeed and baby will bond with mom. Infant's condition stable, skin pink and warm, tolerating feedings, voiding and passing stool. No acute distress and bonding with mom.
Ob / Gyn
Surgery

Newborn Discharge #01
Since admission to the newborn nursery. The baby has been feeding well, stooling, and making adequate wet diapers. Vitals have remained stable. Baby received routine care and passed auditory screening and received HBV. Bilirubin was ____ at ____ hours of life, which is ______ zone. Discharge weight was down _______ from birth weight. Stable for discharge to home after receiving routine newborn care education and instructions to schedule follow up pediatrician appointment.
Ob / Gyn

Nipple Shield #01
Nipple shield need/application/care demonstrated and written materials provided. Effective latch achieved and sustained with milk flow noted.
Ob / Gyn

Pelvic Rest #01
Place nothing in vagina, no intercourse, no tampons, no tub baths, no swimming, no hot-tubs no douching until cleared by your medical doctor.
Ob / Gyn

Eye-surgery Post-op #01
No heavy lifting of straining, this can increase your intra-ocular pressure. Please leave the eye guard in place and keep soap and water out of eye. Do not remove dressing. You were given a Lens implant identification card - please take care of this, make a copy, and bring it with you to doctor appointments and ER visits. Please take care using steps and curbs as depth perception may be altered.
Ophthalmology
Nursing

Arthrocentesis #02
ARTHROCENTSIS PROCEDURE NOTE: Arthrocentesis Indication: Effusion / rule out septic joint Consent: the risks and benefits of arthrocentesis discussed with patient, including the risk of bleeding, infection, and technical failure. The risks of not performing the procedure, failure to diagnose septic joint with resultant systemic infection, discussed with the patient. The alternatives of performing the procedure also discussed. Written consent was obtained following the discussion. Universal Protocol: A timeout was performed and the correct patient and site were verified. The [ ] joint was prepped and draped in proper sterile fashion. The overlying skin was anesthetized with [ ] ml of 1% lidocaine. A [ ] gauge needle was used to aspirate fluid from the joint using appropriate anatomic landmarks. [ ] fluid was obtained from the joint. Approximately [ ] milliliters of fluid was obtained. The fluid was then sent to the lab for appropriate studies. The site was bandaged and no complications were noted. The patient tolerated the procedure well. Post-Procedure Diagnosis: Effusion Complications: None Specimens Removed: fluid only Prosthetic devices/implants: none.
Orthopedic Surgery
Emergency Medicine

Back Pain Discharge #02
HOME CARE INSTRUCTIONS: For many people, back pain returns. Since low back pain is rarely dangerous, it is often a condition that people can learn to manage on their own. Please remain active. It is stressful on the back to sit or stand in one place. Do not sit, drive, or stand in one place for more than 30 minutes at a time. Take short walks on level surfaces as soon as pain allows. Try to increase the length of time you walk each day. Do not stay in bed. Resting more than 1 or 2 days can delay your recovery. Do not avoid exercise or work. Your body is made to move. It is not dangerous to be active, even though your back may hurt. Your back will likely heal faster if you return to being active before your pain is gone. Only take over-the-counter or prescription medicines as directed by your caregiver. Over-the-counter medicines to reduce pain and inflammation are often the most helpful. Your caregiver may prescribe muscle relaxant drugs. These medicines help dull your pain so you can more quickly return to your normal activities and healthy exercise. Please avoid driving, operating heavy machinery or making important decisions while on this drug - it can cloud your judgment. Avoid feeling anxious or stressed. Stress increases muscle tension and can worsen back pain. It is important to recognize when you are anxious or stressed and learn ways to manage it. Exercise is a great option. SEEK MEDICAL CARE IF: You have pain that is not relieved with rest or medicine. You have pain that does not improve in 1 week. You have new symptoms. You are generally not feeling well. SEEK IMMEDIATE MEDICAL CARE IF: You have pain that radiates from your back into your legs. You develop new bowel or bladder control problems. You have unusual weakness or numbness in your arms or legs. You develop nausea or vomiting. You develop abdominal pain. You feel faint.
Orthopedic Surgery
Emergency Medicine

Bursitis Discharge #01
Bursitis is a condition that can cause pain or swelling next to a joint. Rest, cushion, and protect the area. Place an ice pack wrapped in a towel for relief. Take ibuprofen for pain and to decrease inflammation. Be sure to follow up with your primary care physician or orthopedic surgeon for re-evaluation in 2-3 days. RETURN TO THE EMERGENCY DEPARTMENT IMMEDIATELY FOR SEVERE PAIN THAT CANNOT BE CONTROLLED BY MEDICATION, SWELLING OR REDNESS, HIGH FEVER, OR FOR ANY OTHER CONCERN.
Orthopedic Surgery
Emergency Medicine

Radiculopathy Discharge #01
Radiculopathy is a pain, numbness, or tingling when nerves from spinal cord get pinched or damaged. Neck radiculopathy will affect one or both arms - lower back radiculopathy will affect the buttocks or leg. Call your doctor if you have new pain, numbness or tingling that spreads to your arms or legs. Radiculopathy can go away as nerves heal. You may be on pain medication, medication to relax muscles - please take your medications as directed. Please continue with physical therapy.
Orthopedic Surgery
Emergency Medicine

RICE Discharge #01
Rest, Ice (20 minutes at a time, 3 times a day), Compression (ACE wrap or splint), Elevation (above the heart). Follow up with your pediatrician in 1 week if symptoms persist, or with orthopedics if needed.
Orthopedic Surgery
Emergency Medicine

Pain Meds #01
Do not drive, operate heavy machinery and/or make important decisions while on these medications - they can impair your judgment.
Orthopedic Surgery
Neurology

Anterior Cervical Discectomy DC #01
Change bandage on neck daily with provided bandages. Change daily after shower. Cover neck incision daily with plastic cover & tape to keep dry. Wear foam neck-collar daily; you may take it off for meals & showering but keep on at night for sleep. No twisting/turning of head over the shoulders.
Orthopedic Surgery
Neurosurgery

Cervical Discectomy Discharge #01
The patient was admitted for elective anterior cervical discectomy and fusion. The postoperative course was uneventful. PT/OT Worked with patient for acute rehabilitation process. The pain was adequately controlled and patient is able to go home as the patient can accomplish ADL with help from family member at this time. The cervical collar was worn for comfort when out of bed.
Orthopedic Surgery
Neurosurgery

Cervical Laminectomy Discharge #01
The patient was admitted for posterior cervical decompression for (cervical stenosis/ cervical myelopathy), had posterior cervical laminectomy and fusion on XXX. The postoperative course was uneventful. The drain was pulled yesterday without incident and dry dressing placed. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go (home)/ (acute rehab). Medical comorbidities were well controlled during hospital stay.
Orthopedic Surgery
Neurosurgery

Kyphoplasty Discharge #01
The patient was admitted for pathologic, osteoporotic vertebral compression fracture, underwent kyphoplasty in the attempt to control pain and regain independent lifestyle. Vertebral kyphoplasty was performed on XXX. The postoperative course was uneventful. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go home as they can accomplish ADL with help from family members at this time.
Orthopedic Surgery
Neurosurgery

Lumbar Discectomy Discharge #01
The patient was admitted for elective anterior lumbar discectomy and fusion on XXX. The postoperative course was uneventful. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go home as she can accomplish ADL with help from family member at this time.
Orthopedic Surgery
Neurosurgery

Lumbar Laminectomy Discharge #01
The patient was admitted for elective posterior lumbar laminectomy and fusion. The postoperative course was uneventful. Drain was self-removed by patient on post-op day #1. A dry dressing placed and the site was dry on post-op day #2. PT/OT worked with patient for acute rehabilitation process. The patient was started on ANTICOAGULATION for DVT prophylaxis and will continue for XXX weeks postoperatively. The pain is now adequately controlled and patient is able to go (home)/(acute rehab). Medical comorbidities were well controlled during hospital stay. A LSO brace was sized for the patient and provided for use when out of bed.
Orthopedic Surgery
Neurosurgery

Lumbar Laminectomy Discharge #02
Patient was admitted for elective posterior lumbar laminectomy on XXX for failed conservative treatment of persistent lower back pain, The hospital postoperative course was uneventful. The surgical dressing was changed and the drain was removed uneventfully. PT/OT worked with patient for gait training. A TLSO brace was fitted for patient and was used by the patient when out of bed for comfort. Pain was now adequately controlled and patient was discharged home in stable condition. Chronic medical conditions were treated during the hospital stay.
Orthopedic Surgery
Neurosurgery

Orthopedic Revision #01
Patient was admitted on XXX for reimplantation of total XXX hardware. Patient underwent the surgery without complication. Postoperatively, the patient was started on ANTICOAGULATION for DVT prophylaxis. Patient was seen by PT and medicine. Patient was WBAT of the XXX lower extremity. Patient was followed and blood counts were monitored. The patient's pain was treated and controlled using the standard pain management protocol. The wound was monitored. New dressings were applied as indicated. The intra-operative cultures were followed. Antibiotics were continued as medically indicated. The patient was discharged in stable condition.
Orthopedic Surgery
Neurosurgery

Thoracic Laminectomy Discharge #01
The patient was admitted for thoracic decompression, had posterior thoracic laminectomy on XXX. The postoperative course was uneventful. The drain was pulled on XXX without incident and dry dressing placed. PT/OT worked with patient for acute rehabilitation process. Pain is now adequately controlled and patient is able to go (home)/(acute rehab). Medical comorbidities were well controlled during hospital stay.
Orthopedic Surgery
Neurosurgery

Ankle Exam #01
Ankle: skin intact; no deformity; no bony tenderness; dp and pt pulses 2+; capillary refill < 2 seconds; distal sensation intact; strength 5/5 flexion and extension foot/toes.
Orthopedic Surgery
Physical Exam

Back Exam #02
No midline spinal tenderness, no paraspinal tenderness. Strength 5/5 bilateral lower extremity. gross sensation intact bilaterally. deep tendon reflexes 2+ bilateral lower extremity. No clonus. Able to ambulate without difficulty.
Orthopedic Surgery
Physical Exam

Back Exam #03
The entire spine was palpated and nontender. No stepoffs or deformities noted. Skin overlying is intact and atraumatic. There is no paraspinal soft tissue tenderness to palpation. EHL/FHL bl is intact with 5/5 bl lower extremity strength. No saddle anesthesia is present. Normal sensory motor exam. 2+ normal bilateral DTRs LEs. Normal ambulation.
Orthopedic Surgery
Physical Exam

Back Exam #04
No cervical, thoracic or lumbosacral midline bony deformities, +rotation and flexion-extension of neck and truncal area intact.
Orthopedic Surgery
Physical Exam

Knee Exam #01
Quadriceps - No pathology appreciated; Quadriceps ad tendon - No pathology appreciated; Patella - No pathology appreciated; Patellar Tendon - No pathology appreciated; Joint line medial - No pathology appreciated; Joint line lateral - No pathology appreciated; McMurry - No pathology appreciated; Lachman - No pathology appreciated; Popliteal - No pathology appreciated; Neurovascular - No pathology appreciated
Orthopedic Surgery
Physical Exam

Knee Exam #02
Anterior, posterior drawer test and Lachman/Vulgus/Varus test are negative. No bony deformities, +knee flexion and extension intact, cap refill < 2 secs, pedal pulses intact.
Orthopedic Surgery
Physical Exam

Lower Extremity Exam #01
Proximal leg - wnl; Squeeze Test - wnl; Lateral Malleolus - wnl Medial; Malleolus - wnl; Deltoid -wnl; ATFL - wnl CFL -wnl; Achilles - wnl; Base 5th MT - wnl; Peroneals - wnl Neurovascularly intact
Orthopedic Surgery
Physical Exam

Neck Exam #01
The neck is nontender and without pain during active & passive range of motion Patient denies any numbness or weakness of upper or lower extremities. No step offs or deformities appreciated.
Orthopedic Surgery
Physical Exam

Sciatica Exam #01
There is lower lumbar area paraspinal muscle tenseness and tenderness radiating to buttock and lateral calf area. There is no cervical, thoracic or lumbar midline tenderness or bony deformities.
Orthopedic Surgery
Physical Exam

Upper Extremitiy Exam #01
The distal radial and ulnar pulses intact, cap refill < 2 seconds, full range of motion of arm +elbow flexion/extension/supination and pronation intact, +flexion and extension of all digits at DIP and PIP.
Orthopedic Surgery
Physical Exam

Upper Extremity Exam #01
Elbow - FROM, negative tenderness to palpation.; Scaphoid - negative prominence, snuffbox, axial load; DRUJ - negative for any pathology; TFCC - negative for any pathology; No swelling; No bruising
Orthopedic Surgery
Physical Exam

Activity #01
Ambulate as tolerated, increase your distance each time; Change your position every hour in order to minimize pain; No hot tubs, swimming pools or bathtubs until instructed by your surgeon; No driving or operating heavy machinery until cleared by your surgeon
Orthopedic Surgery
Physical Therapy

Hip Surgery Precautions #01
No straight leg raise; No external rotation of hip when extended-standing or lying flat; No hyperextension of hip when standing (kickback); Ice packs to hip for 30 min. every 3 hours & post physical therapy
Orthopedic Surgery
Physical Therapy

Hip Surgery Precautions #02
Do not bend your hip more than 90 degrees; Do not cross your legs or ankles when laying sitting or standing; Do not raise your operated leg up with your knee straight.; Do not bend over at your waist; Avoid sitting in low, soft chairs such as sofas and car seats. You should sit on a chair using firm pillows to raise the height of the seat.; Make sure your bed level is high, so that you maintain proper leg positioning when sitting on the side, or getting in or out; Avoid sitting in low, soft chairs, such as sofas, easy chairs etc.; When entering and traveling by car - Sit in the front passenger seat. Make sure that the car seat is all the way back and semi-reclined before entering; Do not allow your knees to come together when sitting or lying in bed; Do not take a tub bath yet; Do not resume driving until you have your surgeons permission.
Orthopedic Surgery
Physical Therapy

Home Discharge #01
Cleared by physical therapy for home discharge. Discharge instructions and medications have been completed and reviewed with the patient; patient has received a copy. Patient understands hospital course and outpatient instructions. Plan for office follow-up in XXXX days with Dr. XXXX for further evaluation.
Orthopedic Surgery
Physical Therapy

Rehab Discharge #01
Cleared by physical therapy for rehab discharge. Discharge instructions and medications have been completed and reviewed with the patient; patient has received a copy. Patient understands hospital course and outpatient instructions. Plan for office follow-up in XXXX days with Dr. XXXX for further evaluation.
Orthopedic Surgery
Physical Therapy

Shoulder Precautions #01
Keep shoulder elevated in sling at all times. Keep your shoulder close to your body and do not externally rotate shoulder in order to preserve rotator cuff repair. No heavy lifting/pushing/pulling/twisting/weight bearing with shoulder.
Orthopedic Surgery
Physical Therapy

Pre Surgical Testing #01
XXXX y/o XXXX presents for elective procedure XXXX by Dr. XXXX on XXXX day. Presurgical testing and clearance performed, placed in chart.
Orthopedic Surgery
Surgery

Open Reduction and Internal Fixation #01
The patient underwent an OPEN REDUCTION AND INTERNAL FIXATION on XXX for treatment of a XXX fracture. The patient received antibiotics YES/NO. The patient was medically cleared and underwent the procedure and had no intraoperative complications. Post-operatively, the patient was seen by OT/PT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per pain management protocol and the pain was appropriately controlled. The patient was NON-weight bearing. The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery
Trauma

Incision #01
Keep incision area clean and dry. You may shower post operative day X if no drainage present.
Orthopedic Surgery
Wound Care

Incision #02
Keep your incision clean and dry; You may use an ice pack for 20 minutes on and 20 minutes off to decrease pain and swelling.
Orthopedic Surgery
Wound Care

Anterior Cruciate Ligament Discharge #01
Post-Operative Instructions for Anterior Cruciate Ligament Reconstruction: Wound Care- You may remove the Ace Bandage the morning after surgery. Under the Ace is a layer of cotton wrap with small yellow strips. These too may all be removed the morning after surgery. Your wound is held together by layers of internal sutures and white plastic steri-strips. Do not remove these strips, they should stay on until you come for your post-op appointment in 3 weeks. You may take a shower, however, be sure to cover these strips with plastic wrap (ex. Saran wrap) so they do not get wet. You should see your physical therapist within the first 48 hours after surgery to begin therapy. The therapist should follow the prescription given to you upon discharge from the hospital as well as the protocol provided by our office when you booked the surgery. If you did not receive the protocol please call the office for a copy to be faxed to the therapist. If you have not arranged for physical therapy, please call the office for a list of some therapists or contact your insurance company for a list. Brace and Crutches- Upon discharge from the hospital, you will receive a brace and crutches. Be sure to use them when ambulating. You do not need to sleep in the brace. You may stop using both of these devices when you and your therapist feel you are safe without them (about 1-2 weeks). RICE Therapy: Keep your operated leg elevated with some pillows under the ankle. Ice the knee as much as possible for 20 minute intervals. It is important to always ice your knee after you exercise. Please call the office to schedule a follow-up appointment for 3 weeks. Things to look out for: Fever- a temperature of up to 101 degrees Fahrenheit is expected for up to the first two weeks after surgery. If this should occur, take Tylenol every four hours as needed to help reduce the fever. Call the office for fevers over 102 or those which persist and do not respond to Tylenol. Drainage- a small amount of drainage is expected for the first 72 hours. If you have excessive drainage following this period, or any thick or foul smelling drainage from the wound, call the office. Swelling- you may experience swelling for many weeks after the surgery, this is normal. During the first few weeks post-op, the swelling and bruising from the knee may gradually travel down to the calf, ankle, and foot. This may also cause bruising. This is to be expected as an effect of gravity. Wound- If your wound should open, notify the office immediately.
Orthopedic Surgery

Arthrodesis Discharge #01
The patient underwent Arthrodesis on XXXX. Postoperatively the patient received IV antibiotics and was made non-weight bearing. The patient received ANTICOAGULATION for DVT prophylaxis. The patient was seen and evaluated by PT/OT. The patient's pain was controlled. The patient was able to demonstrate how to ambulate without weight bearing on the affected extremity. The patient was instructed on the importance of elevation of the lower extremity. The surgical splint and dressing were changed. The lower extremity was placed into a well padded short leg cast. The patient was cleared by PT and discharged home in stable condition.
Orthopedic Surgery

Hip Discharge Precautions #01
TOTAL HIP PRECAUTIONS: Remember to continue all of the precautions for total hip replacement. Your surgeon will tell you when and if you can move beyond these limitations. Do not bend your hip more than 90 degrees. Do not cross your legs or ankles when lying, sitting, or standing. Do not raise your operated leg up with your knee straight. DO NOT bend over at your waist. Avoid sitting in low, soft chairs such as sofas and car seats. You should sit on a chair using firm pillows to raise the height of the seat. Make sure your bed level is high, so that you maintain proper leg positioning when sitting on the side, or getting in or out. Avoid sitting in low, soft chairs, such as sofas, easy chairs etc. When entering and traveling by car: Sit in the front passenger seat. Make sure that the car seat is all the way back and semi-reclined before entering. Do not allow your knees to come together when sitting or lying in bed. Do not take a tub bath yet. Do not resume driving until you have your surgeons permission.
Orthopedic Surgery

Hip Replacement Discharge #01
The patient underwent a TOTAL HIP REPLACEMENT on XXX. The patient received antibiotics post-operatively. The patient underwent the procedure and had no intraoperative complications. Post-operatively, the patient was seen by medicine and PT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per protocol and the pain was appropriately controlled. Patient was instructed by physical therapy The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery

Hip Surgery Discharge #01
{XXX} year old status post {HIP Surgery} without any intraoperative complications. The patient is doing well and stable for transfer to rehab. Pt is tolerating physical therapy: WBAT, TOTAL HIP PRECAUTIONS, gait training. Staples/sutures to be discharged on post-op day #10. The patient is on {XXX} for DVT prophylaxis but change to {XXX} when pt is discharged from rehab. Follow-up with {SURGEON} in 1 week
Orthopedic Surgery

Knee Arthroscopy Discharge #01
Patient underwent a knee arthroscopy on XXX. The patient will leave the applied dressing on for XXX days. The patient will then remove and apply new dressing daily. Showering and washing the wound may be started after postoperative day # XXX. The office will be contacted for any questions or concerns regarding the wound or other post-operative care. Physical therapy may be started as soon as ready. Pain medications will be taken as directed.
Orthopedic Surgery

Knee Replacement Discharge #01
The patient will be seen in the office in 2-3 weeks for wound check. Sutures/Staples/Tape will be removed at that time. Patient may shower after post-op day #3. The dressing is to be removed on XXX. If the dressing becomes soiled please change. The patient will contact the office if the wound becomes red, has increasing pain, develops bleeding or discharge, an injury occurs, or has other concerns. The patient will continue PT consistent with total knee replacement. The patient is FULL weight bearing. Elevation of the lower leg is recommended to reduce swelling.
Orthopedic Surgery

Knee Replacement Discharge #02
The patient underwent a TOTAL KNEE REPLACEMENT on XXX. The patient underwent the procedure and had no intraoperative complications. Postoperatively, the patient was seen by PT/OT. The patient received ANTICOAGULATION for DVT prophylaxis. The patient received pain medications per protocol and the pain was appropriately controlled. The patient did not have any postoperative medical complications. The patient was discharged in stable condition.
Orthopedic Surgery

Knee Surgery Discharge #01
{XXX} year old status post {Knee Surgery} without any intraoperative complications. The patient is doing well and stable for transfer to rehab. The patient is tolerating physical therapy: WBAT, gait training, CPM 0-45 degrees (advance as tolerated). Staples/sutures to be discharged on post-op day #10. Knee immobilizer on during transportation to rehab then discontinues when the patient is at rehab. The patient is on {XXX} for DVT prophylaxis but change to {XXX} when pt is discharged from rehab. Follow-up with {SURGEON} in 1 week.
Orthopedic Surgery

Orthopedic Procedure Check #01
Please check your toes/fingers for warmth, pink color, circulation and movement. If you have severe pain or discoloration of your extremity please contact your physician immediately.
Orthopedic Surgery

Orthopedic Surgery Discharge #01
The patient will be seen in the office between 2-3 weeks for wound check. Sutures/Staples/Tape will be removed at that time. Patient may shower after post-op day XXX. The dressing is to be removed on day # XXX. The patient will contact the office if the wound becomes red, has increasing pain, develops bleeding or discharge, an injury occurs, or has other concerns. The patient will continue Physical Therapy. The patient will take XXX for pain control and titrate according to prescription and patient needs.
Orthopedic Surgery

Orthopedic Surgery Discharge #02
Please call your Surgeon for follow-up appointment. Please call your Surgeon for any temperature greater than 101, any numbness or tingling in operated extremity, any redness or drainage from wound.
Orthopedic Surgery

Orthopedic Surgery Discharge #03
Activity: Weight Bearing as tolerated, Take short, frequent walks increasing the distance that you walk each day (as tolerated), Change your position every hour to decrease pain and stiffness. Continue the exercises taught to you by your physical therapist. No driving until cleared by the doctor. No tub baths, hot tubs, or swimming pools until instructed by your doctor. Do not squat down on the floor. Do not kneel or twist your knee. Avoid activities that place stress on your knee. Wound Care Keep your incision clean and dry. You may use an ice pack for 20 minutes on and 20 minutes off to decrease pain and swelling.
Orthopedic Surgery

Spine Surgery Discharge #01
{XXX} year old status post {Spinal Surgery} without any intraoperative complications. The patient is weight bear as tolerated, doing well and stable for transfer to rehab. The patient was instructed to call surgeon's office one week to make a follow-up appointment. D/C sutures/staples post-op day #14. NO ANTICOAGULATION, ASPIRIN OR NSAIDS FOR THIS PATIENT - RISK OF EPIDURAL
Orthopedic Surgery

Asthma Discharge #03
Please follow up with your pediatrician in 1-2 days. Continue Albuterol every 4 hours until you see you pediatrician. Continue Orapred for __ more days. Return to ED if patient has chest tightness, shortness of breath, difficulty talking, needs albuterol more frequently than every 4 hours or seems increasingly ill.
Pediatrics
Emergency Medicine

Asthma Discharge #06
Return to the hospital if your child is having difficulty breathing - breathing too fast, using neck muscles or belly to help with breathing. If your child is gasping for air or very distressed, or is turning blue around the mouth, call 911. Use albuterol every four hours until your child is seen by her pediatrician. She will need it every four hours while she recovers from this illness. Your pediatrician will give you instructions on how much longer to use it regularly and when you can go back to using it as needed. Take the Flovent twice daily as prescribed. This is your controller medication, so it needs to be taken every day whether you feel healthy or sick. It is to help prevent you from having an asthma attack.
Pediatrics
Emergency Medicine

Bronchiolitis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink approximately ___ oz. per day Use normal saline and gentile suctioning to clear mucus from the nose. Use a cool mist humidifier to decrease congestion. Monitor for fever, a temperature of 100.4 or higher, and if baby is older than 2 months control fever with Tylenol every 6 hours as needed. Follow up with your Pediatrician within ___ hours from discharge. If you are concerned and your baby develops worsening cough, faster or harder breathing, decreased drinking, decreased wet diapers, decreased activity, or worsening fever despite Tylenol use, please call your Pediatrician immediately. If your child has any of these symptoms: breathing VERY hard, breathing VERY fast, not drinking anything, not making wet diapers, or has any blue coloring please call 911 and return to the nearest emergency room immediately.
Pediatrics
Emergency Medicine

Infant Gastroenteritis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink about ___ oz. per day. Encourage clear liquids at first, then if tolerates can give breast milk/formula/milk/food. Do not dilute the formula. Make sure your child is making urine every 6 hours and has at least 4 wet diapers in 24 hours. Wash hands well, especially after contact -- this illness is very contagious as long as diarrhea or vomiting continues. Change diapers quickly after stool and use diaper ointment to keep skin from becoming irritated and a diaper rash from developing. Monitor for fever (Temperature of 100.4 or higher), if your child has a temperature and is older than 2 months you can give: Tylenol ____ mg every 6 hours as needed. Please follow up with your Pediatrician in ___ hours. If you have any concerns or your child has: continued vomiting, large or frequent diarrhea, decreased drinking, decreased wet diapers, dry mouth, no tears, is less active, ongoing fever if > 2 months old, then please call your Pediatrician immediately. If your child has any signs of dehydrations, stops drinking any fluids, has blood in the stool or vomit, is unable to hold down any liquids, is not urinating, fever in a baby < 2 months of age, acting ill or is difficult to awaken, or has severe abdominal pain, please call 911 or return to the nearest emergency room immediately.
Pediatrics
Emergency Medicine

Pediatric Abdominal Pain Discharge #01
Please follow up with your pediatrician in 1-2 days. Please continue with _______________. No limitations in diet. No limitations in activity, as tolerated. Please contact your pediatrician if your child experiences a return in abdominal pain, fever greater than 100.4, non-bloody diarrhea, decreased eating/drinking, decreased amount of urination or decreased activity Please seek immediate medical attention if your child begins to experience bloody diarrhea, severe abdominal pain, is not eating/drinking, is not urinating, is not responding appropriately to questions or commands/becomes difficult to awaken.
Pediatrics
Emergency Medicine

Pediatric Cellulitis Discharge #01
Routine Home Care as follows: Please continue to take your antibiotic as prescribed. Make sure your child drinks plenty of fluid. Your child should drink approximately ___ oz. of fluid in 24 hours. Please continue to mark the rash with a pen or marker and continue to take pictures of the rash/swelling until your are seen by your primary care doctor. Please follow up with your Pediatrician in _____ hours after discharge from the hospital. If your child has any concerning symptoms such as: decreased eating and drinking, decreased urinating, increased fussiness, worsening redness or swelling outside of the area previously marked, worsening pain, inability to ambulate or use the affected extremity, or ongoing fever please call your Pediatrician immediately. Please call 911 or return to the nearest emergency room if your child develops severe swelling in the affected area, difficulty breathing, or loss of sensation and feeling in the affected area.
Pediatrics
Emergency Medicine

Pediatric Fever Discharge #01
The patient was evaluated by myself and was noted to be completely nontoxic in appearance at time of discharge. The child was smiling, taking oral fluids without any difficulty and well appearing. There is no evidence of systemic toxicity at this time, but the child's parents were advised that the condition could change, and that if the child gets worse in any way to return to the emergency department immediately for reevaluation. They were specifically counselled in signs and symptoms of toxicity to look for: inability to tolerate oral fluids, lethargy, delayed capillary refill, alteration in mental status, or petechial rash.
Pediatrics
Emergency Medicine

Pediatric Gastroenteritis Discharge #01
Routine Home Care as Follows: Make sure your child drinks plenty of fluid. Your child should drink about ___ oz. per day. Encourage clear liquids at first then, if tolerates, can give milk/food. Note that after diarrhea, your child may have temporary lactose intolerance and may have worsening of diarrhea with dairy products. Make sure your child is making urine every 6 hours. Wash hands well, especially after contact - this illness is very contagious as long as diarrhea or vomiting continues. Please follow-up with your pediatrician within 1-2 days following discharge. If you have any concerns or your child has: continued vomiting, large or frequent diarrhea, decreased drinking, decreased urinating, dry mouth, decreased tears, is less active, ongoing fever, then please call your Pediatrician immediately. If your child has signs of dehydration such as crying without tears or no urine for >12 hours, or if your child stops drinking any fluids, if your child has blood in the stool or vomit, if your child is unable to hold down any liquids, acting ill (inconsolable or difficult to awaken), or your child has severe abdominal pain, please return to the emergency room or call 911.
Pediatrics
Emergency Medicine

Pediatric Seizure Discharge #01
Seizure Safety Precautions: Please do not permit your child to swim or bathe unattended as their seizures may put them at greater risk of drowning. If your child experiences a seizure, place them on a flat surface on the ground (somewhere he cannot fall) on their side. Do not put anything in their mouth. Call a physician. If a seizure lasts longer than 3 minutes, administer DIASTAT and call EMS immediately.
Pediatrics
Neurology

Birth History #01
Birth History - Born FT via NSVD, prenatal labs within normal limits, no complications with L&D, no NICU stay.
Pediatrics
Ob / Gyn

Infant Feeding Plan #01
Normal weight loss feeding care plan provided. Pt to feed every 2-3 hours, massage during feeds, do skin to skin as much as possible and minimize caloric expenditure.Infant to have a weight check with Pediatrician within 24 -48 hours.
Pediatrics
Ob / Gyn

Newborn Discharge #02
Routine Home Care Instructions: Please call us for help if you feel sad, blue or overwhelmed for more than a few days after discharge. Umbilical cord care: Please keep your baby's cord clean and dry (do not apply alcohol). Please keep your baby's diaper below the umbilical cord until it has fallen off (~10-14 days). Please do not submerge your baby in a bath until the cord has fallen off (sponge bath instead). Continue feeding child whenever baby shows signs of hunger - keep track of how often your baby feeds and how much and contact your pediatrician if your baby had a longer than typical period without feeding. Please contact your pediatrician and/or return to the hospital if you notice any of the following: Fever (T > 100.4), Reduced amount of wet diapers (< 5-6 per day) or no wet diaper in 12 hours, Increased fussiness, irritability, or crying inconsolably, Lethargy (excessively sleepy, difficult to arouse), Breathing difficulties (noisy breathing, increased work of breathing), Changes in the babys color (yellow, blue, pale, gray),Seizure or loss of consciousness.
Pediatrics
Ob / Gyn

Nursery Discharge #01
The parent(s) requested early discharge from the nursery. The risks were discussed, reasons to seek immediate medical attention were explained, and parents expressed understanding.
Pediatrics
Ob / Gyn

Pediatric Circumcision #02
Circumcision care was demonstrated to the mother with understanding. There was no bleeding, oozing or hematoma noted.
Pediatrics
Ob / Gyn

Poorly Feeding Infant #01
Poorly feeding infant discharge care plan provided. The infant will need to be offered both breasts with improved latch on every 2-3 hours. for 15 -20 minutes. Offer supplemental expressed breast milk and or formula every 2-3 hours, 15-30 ml. Establish and maintain breast pumping regimen every 3 hours.
Pediatrics
Ob / Gyn

Pediatric Sprain Discharge #01
Keep air cast on until you follow up with your pediatrician or orthopedist. Use crutches and no weight bearing for the next 2 days. Then, gradually begin to bear weight as tolerated. Elevate leg above your heart when not in use. Ice for 20 minutes at a time every hour as needed for pain for swelling. Motrin 3 times daily for pain and inflammation. Follow up with your pediatrician or orthopedist in 1 week if pain persists. Recommend physical therapy to strengthen muscles and prevent future injury.
Pediatrics
Orthopedic Surgery

Asthma Discharge #08
On the pediatric floor, the patient was progressively spaced from Q2h to Q4h albuterol treatments and continued on OraPRED for a total of 5 days. The patient will remain on Q4 until seen by a pediatrician within 24-48 hours of discharge.
Pediatrics
Pulmonology

Pediatric Dehydration #01
Please return to the emergency room for persistent vomiting, persistent diarrhea the inability to tolerate liquids, decreased urine output, lethargy, change in mental status or any other concerns.
Pediatrics

Pediatric Hypoglycemia Discharge #01
Your baby may get hungry more often, be sure to feed your baby whenever they are hungry. If your baby gets shaky or has a high pitched cry, be sure to make note how long since the last feed, feed as possible and contact your pediatrician regarding when and how to follow up.
Pediatrics

Back Exam #01
Back/Spine is non-tender. No pain with range of motion. No step-offs appreciated. Deep-tendon reflexes are +2/4, equal and without clonus. Sensory and motor are intact.
Physical Exam
Orthopedic Surgery

Physical Exam #01
Gen: WD, WN, in no acute distress.; HEENT: PERRLA, EOMI. oropharynx clear. ; Neck: Supple, no JVD/Bruit. No thyromegaly. ; Lungs: CTA B/L.; CV: RRR, S1 S2, No M/G/R.; Abd: Soft, ND, NT,No HSM, +BS. ;Ext: No clubbing, no cyanosis, no edema.; Neuro: A/Ox3. Cranial nerve intact. No focal deficit.
Physical Exam

Physical Exam #02
Gen: Alert, NAD; Head: NC, AT, PERRL, EOMI, normal lids/conjunctiva; ENT: B TM WNL, normal hearing, patent oropharynx without erythema/exudate, uvula midline; Neck: +supple, no tenderness/meningismus/JVD, +Trachea midline; Pulm: Bilateral BS, normal resp effort, no wheeze/stridor/retractions; CV: RRR, no M/R/G, +dist pulses; Abd: soft, NT/ND, no hepatosplenomegaly; MSK: no edema/erythema/cyanosis; Skin: no rash; Neuro: AAOx3, no sensory/motor deficits, CN 2-12 intact
Physical Exam

ROS Negative #01
No fever/chills, No headache, No photophobia/eye pain/changes in vision, No ear pain/sore throat/dysphagia, No chest pain/palpitations, No SOB/cough/wheeze/stridor, No abdominal pain, No N/V/D, No dysuria/frequency/discharge, No neck/back pain, No rash, No lower extremity edema, No changes in neurological status/function.
Physical Exam

Bed Mobility #01
In ## weeks, the patient will be able to perform rolling, scooting and bridging independently in bed in order to prevent the development of bed sores.
Physical Therapy

Bedroom Mobility #01
In ## weeks, the patient will be able to ambulate 200 feet w/ ## in order to walk from bedroom to front door to answer the doorbell.
Physical Therapy

Community Mobility #01
In ## weeks, the patient will be able to ambulate 1000 feet w/ ## in order to ambulate to public transportation for medical appointments.
Physical Therapy

Consult #01
Consult received from XXXX department and the chart was reviewed. The patient was received supine in bed, AAOx3 and NAD. The patient denies pain currently. Patient agreed to initial evaluation from Physical Therapist.
Physical Therapy

Crutches #01
The patient was provided with axillary crutches and was given a visual demonstration on safe and effective use. Patient was observed using crutches adequately.
Physical Therapy

Defer #01
The patient deferred Physical Therapy intervention at this time secondary to patient secondary to XXXXX. Patient was advised as to the benefits to participating and risks of not participating. Patient continued to refuse. Primary team notified and will continue to follow and re-attempt at later time
Physical Therapy

Discharge Independent #01
The patient presents without gross impairment and is independent with functional mobility. Therapeutic PT intervention is not indicated at this time. The patient will be d/c from the PT program at this time.
Physical Therapy

Discharge Independent #02
Patient functionally independent as per my evaluation. Cleared for discharge to home with no needs. Providers notified
Physical Therapy

Discharge Rehab #01
Patient is a good rehab candidate. PT will continue to follow and progress as tolerated.
Physical Therapy

Evaluation #01
The patient was seen for evaluation today. The patient was received supine in bed in NAD, AAOx3. The patient demonstrated independence with bed mobility activities and modified independence with sit to stand transfer. The patient demonstrated modified independence with ambulation.
Physical Therapy

No Stairs #01
Unable to safely assess patient on stairs at this time. The patient does not exhibit appropriate pre-requisite skills to safely negotiate unlevel surfaces due to XXXX which will put patient at significant risk for falls and injury.
Physical Therapy

Off Floor #01
The patient is off the floor at this time. Chart reviewed. PT will continue to follow patient and re-attempt at another time.
Physical Therapy

OOB #01
Patient advised that staff supervision/assistance is recommended for all out of bed activities including, but not limited to ambulation. Patient verbalized understanding and agreement.
Physical Therapy

Post Evaluation #02
Patient was left in bed/chair with call bell in reach. The patient was instructed to call RN for assistance as needed. PT to follow and assist patient until discharge home or rehab
Physical Therapy

Post evalutation #01
The patient was left seated in a chair, in NAD, all lines/devices intact and call bell within reach. Nursing staff made aware of patients status and participation in PT today.
Physical Therapy

Sitting #01
Patient performed multi-directional reaching activity in sitting position.
Physical Therapy

Standing #01
Patient performed multi-directional reaching activity in standing postion w/ bed behind pt for safety.
Physical Therapy

Unlimited mobility #01
In ## weeks, the patient will be able to ambulate 1000 feet w/ ## while carrying 2 small grocery bags in order to buy food from the local market.
Physical Therapy

Psychiatric ED Normal #01
Throughout the stay in the emergency department the patient was calm and cooperative, did not exhibit any aggression or agitation. The patient did not require any PRN medications or any physical restraints.
Psychiatry
Emergency Medicine

Suicide Risk Assessment #01
The patient is judged to be a low acute suicide risk and elevated chronic suicide risk. They deny current SI, has denied having any active SI since prior to recent hospitalization, they have no prior NSSIB, they are engaged in treatment and compliant with meds, mood is euthymic, they are hopeful and future-oriented with plans to start DBT program and eventually resume XXX and become a XXX, they have no active substance abuse, they have good social supports, and they have no access to firearms. Chronic risk factors include XXX prior suicide attempts, XXX personality disorder with chronic mood dysregulation and impulsivity, sexual orientation, and limited coping skills and poor frustration tolerance. Patient also with social stressor of turbulent interpersonal relationships. Risk will be minimized by participation in comprehensive outpatient psychiatric treatment.
Psychiatry
Emergency Medicine

Confusion DC #01
HOME CARE INSTRUCTIONS: What family and friends can do: To find out if someone is confused ask him or their name, age, and the date. If the person is unsure or answers incorrectly, he or she is confused. Always introduce yourself, no matter how well the person knows you. Often remind the person of his or her location. Place a calendar and clock near the confused person. Talk about current events and plans for the day. Try to keep the environment calm, quiet and peaceful. Make sure the patient keeps follow-up appointments with their physician. PREVENTION: Ways to prevent confusion: Avoid alcohol, Eat a balanced diet. Get enough sleep. Do not become isolated. Spend time with other people and make plans for your days. Keep a careful watch on your blood sugar levels if you are diabetic. SEEK IMMEDIATE MEDICAL CARE IF: You develop severe headaches, repeated vomiting, seizures, blackouts or slurred speech. There is increasing confusion, weakness, numbness, restlessness or personality changes. You develop a loss of balance, have marked dizziness, feel uncoordinated or fall. You have delusions, hallucinations or develop severe anxiety. Your family members think you need to be rechecked.
Psychiatry
Geriatrics

Dementia DC #01
HOME CARE INSTRUCTIONS: The care of individuals with dementia is varied and dependent upon the progression of the dementia. The following suggestions are intended for the person living with, or caring for, the person with dementia: Create a safe environment. Remove the locks on bathroom doors to prevent the person from accidentally locking himself or herself in. Use childproof latches on kitchen cabinets and any place where cleaning supplies, chemicals, or alcohol are kept. Use childproof covers in unused electrical outlets. Install childproof devices to keep doors and windows secured. Remove stove knobs or install safety knobs and an automatic shut-off on the stove. Lower the temperature on water heaters. Label medicines and keep them locked up. Secure knives, lighters, matches, power tools, and guns, and keep these items out of reach. Keep the house free from clutter. Remove rugs or anything that might contribute to a fall. Remove objects that might break and hurt the person. Make sure lighting is good, both inside and outside. Install grab rails as needed. Use a monitoring device to alert you to falls or other needs for help. Reduce confusion. Keep familiar objects and people around. Use night lights or dim lights at night. Label items or areas. Use reminders, notes, or directions for daily activities or tasks. Keep a simple, consistent routine for waking, meals, bathing, dressing, and bedtime. Create a calm, quiet environment. Place large clocks and calendars prominently. Display emergency numbers and home address near all telephones. Have a consistent nighttime routine. Ensure a regular walking or physical activity schedule. Involve the person in daily activities as much as possible. Limit napping during the day. Limit caffeine. Attend social events that stimulate rather than overwhelm the senses. Encourage good nutrition and hydration. Reduce distractions during mealtimes and snacks. Monitor chewing and swallowing ability. Continue with routine vision, hearing, dental, and medical screenings. Only give over-the-counter or prescription medicines as directed by the caregiver. Monitor driving abilities. Do not allow the person to drive when safe driving is no longer possible. Register with an identification program which could provide location assistance in the event of a missing person situation. SEEK MEDICAL CARE IF: New behavioral problems start such as moodiness, aggressiveness, or seeing things that are not there (hallucinations). Any new problem with brain function happens. This includes problems with balance, speech, or falling a lot. Problems with swallowing develop. Any symptoms of other illness happen. Small changes or worsening in any aspect of brain function can be a sign that the illness is getting worse. It can also be a sign of another medical illness such as infection. Seeing a caregiver right away is important. SEEK IMMEDIATE MEDICAL CARE IF: A fever develops. New or worsened confusion develops. New or worsened sleepiness develops. Staying awake becomes hard to do.
Psychiatry
Geriatrics

Dementia Discharge #03
There is no formal treatment for dementia, only symptom management. Behavioral disturbances usually worsen as the disease progresses. Patient at this time is not a candidate for inpatient psychiatric treatment as it would not alter the prognosis/symptoms of the illness. Patient cannot benefit from group therapy and/or individual therapy at this time due to inability to engage meaningfully with the environment. If family is unable to properly care for patient at home, pt would be best served in a nursing home where there is a high level of care, supervision, and often have dementia units where wandering/elopement risk and agitation are addressed.
Psychiatry
Geriatrics

Dementia Discharge #01
Upon careful evaluation of Patient's past psychiatric history, the course of illness including symptoms/severity/variation, as well as current symptomatology and clinical psychiatric presentation, it is with a high degree of clinical certainty that Patient has a primary diagnosis of dementia, advanced stage. Patient exhibits severe, multi-area cognitive deficits of aphasia, apraxia, agnosia, short-term memory loss, intermediate and long-term memory loss, episodic memory loss, personality changes, disorientation, diurnal variation, disorganized behavior consistent with advanced-stage degenerative dementia process. Subsequently, Patient cannot benefit from group therapy and /or individual therapy at this time. Summary: Patient is an AGE GENDER with multiple medical co-morbidities and advanced stage dementia (likely Alzheimer's subtype, late onset with delusions and behavioral disturbances) with unavoidable worsening symptoms as the neurodegenerative disease progresses. Patient's symptoms and behaviors will worsen as it is an unavoidable manifestation of the progressing neurodegenerative disease in its advancing stages. There is no formal treatment for dementia only symptom management. Patient at this time is not a candidate for inpatient psychiatric treatment as it would not alter the prognosis or symptoms of their illness; Patient cannot benefit from group therapy and /or individual therapy at this time due to inability to engage with their environment. Subsequently, Patient at this time would benefit from placement in an appropriate skilled nursing facility or nursing home. This was discussed with XXX. recommending social work involvement at this point as XXX DOES / DOES NOT feel comfortable / safe having him returned home.
Psychiatry
Neurology

Depression Symptoms ROS Negative #01
Patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry
Neurology

Depression #01
Patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry

Depression DC #01
SEEK IMMEDIATE CARE IF: You have thoughts about hurting yourself or others. You lose touch with reality (have psychotic symptoms). You are taking medicine for depression and have a serious side effect
Psychiatry

Depression Negative ROS #01
The patient denies any depressive symptoms including depressed mood, anhedonia, changes in energy/concentration/appetite, sleep disturbances, or feelings of guilt.
Psychiatry

Depression Positive ROS #01
The patient demonstrated depressive symptoms including persistent sad mood, hopelessness, helplessness, worthlessness, anhedonia, guilt feelings, difficulty concentrating, fatigue, decreased appetite, low motivation and difficulty falling asleep, lasting for XXX weeks.
Psychiatry

Manic #01
Patient denies manic symptoms including elevated mood, increased irritability, mood lability, distractibility, grandiosity, pressured speech, increase in goal-directed activity, or decreased need for sleep.
Psychiatry

Mood #01
The patient's mood is congruent, has normal range, intensity, and is non-labile
Psychiatry

Protective Factors #01
Protective factors include no suicide attempts, no violence history, medication compliance, no access to guns, no global insomnia, no substance abuse, supportive family, willingness to seek help, no suicidal ideation or homicidal ideation, hopefulness for future.
Psychiatry

Psychiatric negative history #01
The patient has not had any prior psychiatric visits, hospitalizations, medication trials or visits with a therapist or a counselor. No history of suicidality, suicidal attempts or self-injurious behavior in the past.
Psychiatry

Psychotic Symptoms Negative #01
The patient denies any psychotic symptoms including paranoia, ideas of reference, thought insertion/broadcasting, or auditory/visual/olfactory/tactile/gustatory hallucinations.
Psychiatry

Safer Discharge #01
Safety planning is done with patient and family. The family was advised to secure all sharps and medication bottles out of patient's reach at home. The family denies having any firearms at home. They were advised to call 911 or take the patient to the nearest ED if patient's behavior worsened or if there are any safety concerns. The family verbalized understanding.
Psychiatry

Suicide Risk Factors #01
Risk factors include: depression, anxiety symptoms, impulsivity, history of self- injurious behavior, prior suicidality, previous suicide attempts, prior hospitalizations, positive family history, history of substance abuse, multiple stressors, academic decline, absence of outpatient follow-up, poor insight into symptoms, poor reactivity to stressors, difficulty expressing emotions, low frustration tolerance, medication non-compliance.
Psychiatry

Smoking #01
Most former smokers quit without using one of the treatments. However, the following treatments are scientificy proven to be effective for smokers who want help to quit: 1) Brief help by a doctor (such as when a doctor takes 10 minutes or less to give a patient advice and assistance about quitting) 2) Individual, group, or telephone counseling 3) Behavioral therapies (such as training in problem solving) 4) Treatments with more person-to-person contact and more intensity (such as more or longer counseling sessions) 5) Programs to deliver treatments using mobile phones 6) Medications for quitting that have been found to be effective include the following: Nicotine replacement products; Over-the-counter (nicotine patch [which is also available by prescription], gum, lozenge); Prescription (nicotine patch, inhaler, nasal spray); Prescription non-nicotine medications: bupropion SR (Zyban), varenicline tartrate (Chantix)
Pulmonology
Medicine

Asthma Admit #01
The patient's asthma was diagnosed at age {XXX}. He/She has had {XXX} hospitalizations, {XXX} ICU stays, {XXX} intubations. He/She uses albuterol {XXX}. He/She is/is not on a controller medication. Precipitating factors include {XXX}. He/She has symptoms {XXX}days per week and {XXX}night-time awakenings per week. He/She has a history of eczema/allergies.
Pulmonology
Pediatrics

Asthma Discharge #01
Please seek immediate medical attention if the {you/your child} requires albuterol more than every four hours, is having difficulty breathing, pulling on ribs or neck, nasal flaring, unresponsive or more sleepy/drowsy than usual or for any other concerns.
Pulmonology
Pediatrics

Asthma Discharge #07
Return to the hospital if your child is having difficulty breathing. Signs of this include, but are not limited to: breathing too fast, using neck muscles or belly to help with breathing or nasal flaring. If your child is gasping for air, appears very distressed, or is turning blue around the mouth, call 911.
Pulmonology
Pediatrics

COPD DC #01
Call your primary care doctor upon arrival home to make a follow-up appointment within one week. Take all inhalers (e.g. Proventil) and steroids (e.g. Prednisone) as prescribed by your doctor. If your cough increases in frequency and severity and/or you have increased shortness of breath call your doctor If you develop fever, chills, night sweats, malaise, and/or change in mental status call your doctor. Increase your activity as tolerated. Do not stay in bed all day. Please do not smoke. Please continue using oxygen as home, if indicated.
Pulmonology
Respiratory

Extubation #01
Written order for extubation verified. The patient was identified by full name and birth date by the identification band. Present during the procedure were XXXX. The patient tolerated the procedure well and was placed on XXXX.
Pulmonology
Respiratory

Extubation #01
Orders to extubate. The patient is able to lift the head off the pillow. Extubated by respiratory therapy, able to expectorate secretions, voice soft but clear. 40% AFM in place O2 sat> 92%.
Pulmonology
Respiratory

Incentive Spirometer #01
The patient was importance and use of an incentive spirometer, coughing, and deep breathing exercises. A demonstration was provided. The patient verbalizes and demonstrates understanding.
Pulmonology
Respiratory

Incentive Spirometer #02
Incentive spirometer given to the patient and educated on proper use. The patient verbalized understanding and demonstrated appropriate use of incentive spirometer.
Pulmonology
Respiratory

Social Work #01
The social worker will continue to provide therapeutic and supportive counseling including concrete services and discharge planning. Referrals to outside agencies in the community will be made if necessary, and assessment will be ongoing until discharge from the hospital.
Social Work
Medicine

Cholecystitis DC #01
HOME CARE INSTRUCTIONS: Home care will depend on your treatment. If you were given antibiotics, take them as directed. Finish them even if you start to feel better. Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your doctor. Follow a low-fat diet until you see your caregiver again. Keep all follow-up visits as directed by your caregiver. SEEK IMMEDIATE MEDICAL CARE IF: Your pain is increasing and not controlled by medicines. Your pain moves to another part of your abdomen or to your back. You have a fever. You have nausea and vomiting
Surgery
Gastroenterology

Cholelithiasis DC #01
Gallstones are stones in the gallbladder that can block the gallbladder from draining bile. Please call your doctor if you develop severe stomach pain. This pain is usually located on the right side under your rib cage. This pain can radiate to the back or right shoulder. You can also develop nausea & vomiting. Rare complications that can occur include infections, gallbladder tears, and pancreas inflammation. You can help prevent gallstone formation by keeping a healthy weight - overweight people are more likely to get gallstones. However, losing weight too quickly can lead to gallstone formation so speak with your doctor before starting any dietary regimen.
Surgery
Gastroenterology

Diverticulitis #01
XXX year old Male / Female presents with XXX days of abdominal pain. The pain was sharp, crampy eventually with radiation to the XXX. The patients measured temp was XXX. The patient denies chills, diarrhea, dysuria, nausea or vomiting. The CT scan w/ oral and iv contrast showed diverticulitis with/without a collection.
Surgery
Gastroenterology

Small Bowel Obstruction Discharge #01
A bowel obstruction can occur when scar tissue forms inside the abdomen after a surgical procedure, causing a kink in the intestines. In some cases, food movement is totally blocked; with a partial bowel obstruction a limited amount of food can move through. Symptoms usually come on suddenly, and can be severe acute pain in the abdomen with nausea or vomiting. Most people affected by a bowel obstruction are unable to pass gas or have a bowel movement, and may have a swollen abdomen. Infrequent bowel movements or hard stools usually do not indicate obstruction. If you have bowel obstruction symptoms it is important to see a doctor right away. Partial bowel obstruction may be treated in a hospital setting with a few days of bowel rest, a technique in which any remaining food is drained from a patients stomach and further food is eliminated. Intravenous fluids help you stay hydrated. If bowel rest does not work or bowel tissue begins to die due to the blockage, surgery may then be attempted. If you have a complete obstruction, immediate surgery is required.
Surgery
Gastroenterology

Reassess #01
The patient is stable - pain is well controlled, tolerating diet and voiding appropriately.
Surgery
General

Presurgical call #01
Pre-op call made by the provider. Spoke with patient XXXX. We advised on NPO status after XXXX time. Instructions given: no eye make-up, contacts, jewelry or piercings. Please bring a picture ID, a medical insurance card and to wear comfortable clothing. Please be aware an accompanying adult is required to provide a ride home. Please take any medication you were instructed to take in the morning with a small sip of water. Please review written instructions you received in Pre-Surgical Testing. Provider reviewed and answered any additional questions.
Surgery
Nursing

Laparoscopic Gas #01
You may experience some gas pains from residual carbon dioxide that may remain in your abdomen following the procedure. The pain usually presents as shoulder pain or sharp pain underneath your diaphragm. The pain is usually transient and will disappear in a day or two. It helps if you get up and move around while you are having this pain.
Surgery
Ob / Gyn

SAVI Procedure #01
Excision of breast mass through peri-areolar incision using Savi Scout marker localization. Biopsy clip & Savi Scout marker identified on intraoperative imaging. Additional breast tissue excised for margin. Hemostasis achieved. Local tissue rearranged using XXX sutures. Primary closure using XXX sutures w/ Steri-strips.
Surgery
Plastic Surgery

Interventional Radiology #01
Interventional radiology placed a XXX drain. Please follow up with interventional radiology to have your drain evaluated one week from discharge. Please call today to schedule an appointment (from one week from discharge date). Continue to empty and record the drain output daily as you have been taught.
Surgery
Radiology

Dressing #01
Patient's dressing is clean, dry, and intact. No drainage or odor present.
Surgery
Wound Care

Incision #01
Wash incisions with soap and water in shower daily, apply friction to release scab formation
Surgery
Wound Care

JP Drain #01
You will be discharged with Jackson-Pratt (JP) drains. You will need to empty them and record outputs accurately. You will be instructed by nursing staff on how to empty these drains. Please do not remove, manipulate or damage the JP drains. The JP drains will be removed in the office in a subsequent follow-up visit. Please bring a record of the JP drain output with you to the follow-up office visit.
Surgery
Wound Care

Steri-strips
Please allow sterile-strips to fall off on their own. It is ok to shower and rinse wound with warm soapy water. Do not scrub wound as this will disrupt the healing, instead pat dry. Please call the doctor immediately if you develop fever, chills, inability to tolerate liquid or food, diarrhea, nausea, vomiting or increased abdominal pain. Follow a regular diet. Do not drive or operate machinery while taking narcotic pain medication they can make your sleepy and impair your judgement.. Please follow up with your doctor within 1 week of discharge.
Surgery
Wound Care

Wound Care #01
Wound Care daily: Please pack the WOUND LOCATION openings with 1-inch sterile packing and then cover (including staples) with dry, sterile gauze and paper tape. Please contact your Surgeon if you develop any severe pain, copious and/or foul smelling discharge from the site, fevers or chills.
Surgery
Wound Care

Wound Vac Care #01
The wound vac dressing collapsed, adequate seal, suction maintained as per MDs order. Monitored q2h.
Surgery
Wound Care

Appendicitis #01
The patient presented with a clinical picture and objective findings, consistent with acute appendicitis. Medicar
SOAPnote Home
SOAPnote Home
SOAPnote Home
SOAPnote Homel records were obtained and reviewed. The patient was educated on the clinical findings and the expected inpatient course. The patient agrees to admission and to be taken to OR for appendectomy.
Surgery

Appendicitis #02
Based on clinical and objective findings the patient was found to have Acute Appendicitis and was admitted to the surgery service to undergo Laparoscopic Appendectomy. The patient tolerated the procedure well and was transferred to the floor in stable condition. On POD #1, the patients diet was advanced as tolerated and they were placed on oral pain medication. Once the patient was ambulating well, voiding without difficulty, and tolerating a full diet, they were found to be stable for discharge to home. The pain was well-controlled at the time of discharge. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Appendicitis #02
XXX year old Male / Female presents with XXX days of diffuse abdominal pain. The pain radiated to the RLQ +/- nausea +/- vomiting +/- fevers +/- chills +/- diarrhea +/- constipation +/- melena +/-hematochezia. WBC was XXX with shift. CT scan showed acute appendicitis.
Surgery

Bariatric Diet #01
Bariatric protocol diet (clear liquid diet for two days after surgery, then advance to full liquid diet with protein shakes). Start taking your vitamins when you return home. All medications must be in crushed/liquid/chewable/dissolvable form.
Surgery

Bariatric Surgery Hospital Course #01
{XXX} year old {XXX} with past medical history of morbid obesity and {XXX} with a BMI of {XXX} presents for elective bariatric surgery. Patient underwent {XXX} on {XXX}. Surgery was uncomplicated. On post-op day 01, clear liquid diet was initiated and tolerated by the patient. The patient was seen by a registered dietician prior to discharge. Patient ambulating, voiding, and stable for dc home on {XXX}. All questions addressed and answered, anticipatory guidance provided.
Surgery

Cardiothoracic Surgery Discharge #01
Take medications as prescribed. Follow up with your doctor as directed. Shower daily with mild soap & water, pat incisions dry. No washcloth on wounds. No oils/lotion/cream on incision sites. Increase activity slowly, as tolerated. No driving or heavy lifting for 4 weeks. Continue to use your spirometer & perform your deep breathing & coughing exercises as directed. Use red heart pillow under your seat belt for safety & use it when coughing for comfort. Eat a heart healthy diet low in salt, sugar & fat. Call your surgeon for fever over 101 degrees, pain not relieved by pain medication or if redness, swelling or oozing is noted @ incision sites. Call 911 for chest pain, shortness of breath, signs & symptoms of stroke.
Surgery

Cardiothoracic Surgery Discharge #02
Take medications as prescribed. Be sure to follow up with doctor appointments. If you should experience chest pain or shortness of breath call 911. Wash incision site daily with mild soap and water in the shower. Pat dry. Monitor site daily for symptoms of infection including redness, swelling, warmth, tenderness, or increased drainage. If you should experience any of these symptoms, or develop a fever, call your doctor.
Surgery

Cholecystitis #01
The patient presented with a clinical picture and objective findings, consistent with acute cholecystitis. Medical records were obtained and reviewed. The patient was educated on the clinical findings and the expected inpatient course. The patient agrees to admission and to be taken to OR for laparoscopic cholecystectomy..
Surgery

Cholecystitis #02
Based on clinical and objective findings the patient was found to have gallbladder pathology and admitted to the surgery service to undergo a Laparoscopic Cholecystectomy. The patient tolerated the procedure well and was transferred to the floor in stable condition. His diet was advanced, and he was placed on PO pain medication. Once he was ambulating well and voiding without difficulty, he was found to be stable for discharge to home. Pain was well controlled at the time of discharge and the patient was tolerating a full diet. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Cholecystitis #03
XXX year old Male / Female presents with XXX days presents with RUQ abdominal pain that began XXX days ago. +/- nausea +/- bilious emesis +/- hematochezia +/- fevers +/- chills +/- melena +/- diarrhea +/- constipation. The patient **does/does not** have a prior history of biliary colic. Laboratory studies show a WBC of _ and LFTs that **are / are not** elevated. Amylase and lipase **are / are not** within normal limits. An ultrasound shows gallstones with thickened gallbladder wall and pericholecystic fluid. The common bile duct was XXX cm in diameter. These results are consistent with acute cholecystitis.
Surgery

Diverticulitis #01
The patient was admitted with the diagnosis of diverticulitis and placed on bowel rest. IV antibiotics were started and serial abdominal exams were performed. Once the patient's abdominal pain began to improve, his diet was then restarted and slowly advanced as tolerated. As of hospital day XXX the patient's pain had resolved and he was tolerating a regular diet without nausea, vomiting, or abdominal pain. The patient was voiding well and ambulating without difficulty at the time of discharge. The patient will follow-up in the surgeons office in 1 week for checkup.
Surgery

Gastric Sleeve #01
M/F here a Same Day Admission for lap sleeve gastrectomy. The patient tolerated the procedure well. Post-operatively, the patients UGI was within normal limits. At time of discharge, the patient was tolerating a bariatric clear liquid diet, and the patients pain was controlled. Plan is to follow up with Dr. ____ in the office.
Surgery

Hernia #01
Based on clinical and objective findings the patient was found to have hernia pathology and was admitted to undergo bilateral inguinal hernia repair. The patient tolerated the procedure well and was transferred to the floor in stable condition. Their diet was advanced as tolerated and they were placed on oral pain medication. On POD #1, he was voiding without difficulty and ambulating well. Once his pain was well-controlled, he was found to be stable for discharge to home. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

JP Drain #02
Continue JP drain care as instructed. (Empty and record the JP drainage twice daily after discharge. Also, strip/milk the drain tubing each time to minimize clogging. Bring the recorded drain amounts to the office so that it can be reviewed by the physician.) Showers are permitted the day of discharge. The drains and the incision lines can get wet in the shower. Do not take a bath. Pin the drains to a bathrobe belt or string or a small towel draped over your neck in order that the drains do not dangle from your skin while in the shower. Keep incision sites and JP drain sites clean & dry after showering.
Surgery

Mastectomy #01
The patient is a XX YO female who was admitted to undergo LEFT/RIGHT Mastectomy. She tolerated the procedure well and was transferred to the floor in stable condition. Her diet was advanced as tolerated and she was placed on PO pain medication. On POD #1, she was ambulating well and voiding without difficulty. She was then found to be stable for discharge to home. Her pain was well-controlled at the time of discharge. The patient will follow-up in the surgeons office in 1 week for post-operative check up.
Surgery

Surgery Discharge #01
The patient was admitted to XXX for surgery. The operation was uncomplicated and post-operative course was uneventful. The patient is tolerating a diet without nausea/vomiting, ambulating without difficulty, and voiding spontaneously with bowel function. The patients pain is well controlled on oral pain medication. The patient is deemed ready for discharge and will follow up with the surgeon.
Surgery

Surgery Discharge #01
The patient was brought to the operating room on XXXX for an operative procedure. Patient tolerated the procedure well with no known complications. Patient pain is well controlled, tolerating diet ambulating and voiding. All patient questions were addressed and answered. The patient is stable for discharge and is to follow up as an outpatient with his primary care doctor and primary surgeon.
Surgery

Surgery Discharge #02
The patient had XXX and required XXX performed in the operating room. Post-operatively the patient was sent to the PACU, the patient monitored and was hemodynamically stable and was subsequently sent to a surgical floor. The patient had daily wound care and was seen by physical therapy who recommended home/rehab. The patient's pain was controlled by IV pain medications and then transitioned to oral narcotics. The patient was advanced to regular diet and tolerated it well. Successful trial of void on post-op day XXX. Drains were removed prior to discharge. The patient was hemodynamically stable and was placed on home medications. The patient was told to follow up with Dr. XXX in 1-2 weeks and had no other issues.
Surgery

Trauma Activation #01
Level XXX Trauma Activation. The trauma team is at the bedside for evaluation. See trauma flow sheet for initial patient assessment and medications given.
Trauma
Emergency Medicine

Benign Prostatic Hypertrophy Discharge #01
You have an enlarged prostate gland which gets bigger as men get older - it is a very common problem. Call your doctor if you are urinating more frequently, have trouble starting to urinate, have a weak stream, urine leaking or dribbling, and feeling as though bladder is not empty after urination. Your doctor will monitor your prostate with a rectal exam as well as urine or blood testing. You can help yourself by reducing the amount of fluid you drink before going to bed, limiting the amount of alcohol & caffeine you drink. Please avoid cold & allergy medication that contain decongestants or antihistamines which make BPH symptoms worse. You can also "double void" by waiting a moment after urinating & trying again. Take your medication as prescribed.
Urology
Medicine

Foley Care #01
Please keep track of your hourly urine output. If you notice that your urine output has decreased for more than an hour please increase your water consumption. If this persists despite increases in your liquid intake or you develop and/or swelling in the suprapubic region (below your belly-button) please call your urologist. Do not allow the catheter to restrict your activity. Moving about and walking are important.
Urology
Nursing



r
Lithotripsy Post-op #01
It is not uncommon to have some burning when you urinate or to even notice some stone fragments in your urine. This more than likely will pass in the next 24 hours. Please ensure adequate hydration and follow-up with your urologist as an outpatient.
Urology
Nursing

Urology Post-op #01
It is common to have blood in the urine after your procedure. It may be pink or red. If you have significant amount of clots in urine, difficulty urinating or inability to urinate inform your doctor immediately. Drink plenty of water. Do not perform strenuous activities or resume sexual activity until you are cleared by your doctor.
Urology
Nursing

Varicocele Post-Op #01
A small amount of blood is expected. Bruising (black and blue) scrotum and the penis is expected - this should resolve in a couple of weeks. Please removed the dressing and shower as instructed by your physician. No heavy lifting or sports until cleared by your physician. No sexual activity until cleared by your physician.
Urology

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